NRSG353 - Acute Care Nursing 2

Week 1:

Trigger 1: (Josephine)

What is the pathophysiology of COPD?

COPD which is known as Chronic obstructive pulmonary disease is an airway disease
or term which can be categorised as an airway obstruction. COPD involves conditions
such as emphysema, chronic bronchitis and asthma. When an obstruction or
prolonged reduction in airflow occurs, it causes the gas exchange to become restricted
or reduced. The gas exchange occurs in the lungs, involving the bronchioles, bronchi,
alveoli and the blood vessels, which all work together as part of the respiratory system.
A major impact of COPD is chronic inflammation that causes a variety of
complications. The inflammation is related to different changes and responses within
the respiratory system, with the main characteristic being the narrowing of the airways
which can be linked to emphysema and chronic bronchitis. The inflammation can be a
response to issues including an increase to goblet cells, remodelling of airway
structure & mucous secreting glands and reduced elasticity of the alveoli and smooth
muscles. The impact on the respiratory system causes ineffective lung function which
when affected long-term can cause COPD. Long term effects create changes to the
airflow which would not be reversible. The changes can cause complications with
ventilation and inadequate gas exchange within in the alveoli, resulting in cardiac and
circulation problems.

Common signs and symptoms of COPD are the following;

1. Difficulty in breathing or wheezing
2. The patient might have coughing fits going on
3. Signs of lip breathing might occur
4. The accessory muscle can be used
5. Signs of confusion or disorientation
6. Skin maybe cool to touch
7. Changes to skin colour (this could lead to cyanosis)
8. O2 sats might be low

References:

Mitchell, J. (2015). Pathophysiology of COPD: Part 1. Practice Nursing, 26(4), 172-

178. doi: https://doi.org/10.12968/pnur.2015.26.4.172

Trigger 2: Bridgette
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1. How much oxygen can you administer with COPD? Link this back to the
pathophysiology and explain why?
- sats aimed → 88%-92%
- PaO2 → range of 55 - 60
- COPD patients are dependent on hypoxic drive
- they need more Co2 to trigger normal breathing

2. What are the causes for right sided chest pain?

● Angina
● Trauma

- penetrating foreign objects

- sternal or rib fracture
- seatbelt bruising

● pneumothorax
● pulmonary hypertension
● pulmonary embolism
● Flail chest
● Aortic rupture

Trigger 3: (Nav)

1. What is the rationale for ECG and CXR?

CXR: Chest x-ray produces a black and white image of your heart, lungs, airways,
main blood vessels and the bones in your chest and spine. It helps physicians identify
if the symptoms such as SOB is caused by a heart or lung condition. If CXR
determines a heart condition then the physician orders more tests. Common heart
conditions assessed by CXR include Heart failure, Pericarditis, Congenital Heart
Disease
ECG: ECG is a simple test which records the rhythm and electrical activity of heart.
Small sticky patches called electrodes are put on arms, legs and chest. These are
connected by wires to an ECG recording machine which picks up the electrical signals
that makes the heart beat. This electrical activity is recorded and printed onto paper.
An ECG can help detect problems with the heart rate or heart rhythm– called
arrhythmias. It enables the physicians to determine if a patient is having a heart attack
or if the patient has had a heart attack in the past. Sometimes an ECG can indicate if
heart is enlarged or thickened. An ECG is usually one of the first heart tests performed
for chest pain. It does have some limitations, so often patients undergo one or more
other tests too. An abnormal ECG reading doesn’t always mean there is something
wrong with the heart.

2. What are the expected findings?

Expected findings CXR Include:
● heart failure and other heart problems
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● Pneumonia
● Emphysema
● Lung Cancer
● positioning of medical devices
● fluid or air collection around the lungs
Expected findings for ECG Include:
● enlargement of the heart
● congenital heart defects involving the conducting (electrical) system
● abnormal rhythm (arrhythmia) – rapid, slow or irregular heart beats
● coronary occlusion
● poor blood supply to the heart
● abnormal position of the heart
● heart inflammation – pericarditis or myocarditis
● cardiac arrest during emergency room or intensive care monitoring
● disturbances of the heart’s conduction system
● imbalances in the electrolytes that control heart activity
● previous heart attacks.
3. How will you give the drug?
Salbutamol can be administered as:
A) Via a nebuliser in a nebulised solution (5mg/2.5 ml).
In this salbutamol can be given via nebuliser or as a continuous nebulised
solution via a syringe driver.
B) VIa Intravenous route as IV solution (500mcg/1ml or 5mg/5ml).
In case of bronchospasm/ asthma a loading bolus dose of 500mcg can be
given as a slow bolus over 2-10 mins. An infusion of salbutamol can be given
at a rate of 3ml/hr to 12ml/hr depending on patient response.

4. What are the adverse effects of salbutamol?

Salbutamol is a bronchodilator, Beta (β) -2 adrenoreceptor stimulant, with
some β -1 effects at high dosage levels. β - 1 stimulation causes an increase in heart
rate, contractility and excitability. β - 2 stimulation causes bronchodilation and
vasodilation.
Relief of severe bronchospasm, Relief of bronchospasm in asthma. Any other cause of
bronchospasm, such as: Anaphylaxis, Smoke inhalation, Pulmonary oedema
Pneumonia, Bronchitis, Shortness of breath with expiratory wheeze.
Adverse Effects:
● Increase in heart rate. This response is dose dependent, but is rarely a major
problem.
● Hypotension may occur.
● By affecting pulmonary mismatch, can actually cause increased hypoxia
(“paradoxical hypoxia”). Hence pulse oximetry and supplemental oxygen
should be used.
● Fine tremor: Due to a direct action on skeletal muscle. Occurs in 20% of
Patients.
● Hand tremors, nervousness and restlessness. Less common reactions such
as nausea, vomiting and dizziness have been reported.
● Slight stinging / pain or a sensation of warmth may occur after injection
Hypokalaemia
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5. Why is salbutamol used for COPD?

For most people with COPD, short-acting bronchodilator inhalers are the first
treatment used. Bronchodilators are medications that make breathing easier by
relaxing and widening your airways.
There are two types of short-acting bronchodilator inhaler:
● beta-2 agonist inhalers – such as salbutamol and terbutaline.
● antimuscarinic inhalers – such as ipratropium
Short-acting inhalers should be used when you feel breathless, up to a maximum of
four times a day.

Reference:

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0020/306416/
liverpoolSalbutamol.pdf
https://www.bhf.org.uk/informationsupport/tests/ecg
https://www.radiologyinfo.org/en/info.cfm?pg=screening-cardiac
https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/ecg-test

Trigger 4: (Georgia)

1. What are the common causes of dyspnoea?

Trigger 5: (Cody)

1. What is a pneumothorax?
A pneumothorax is also known as a collapsed lung, and occurs when air has entered
the pleural space between the lungs and chest wall. The air increases pressure in the
area surrounding the lungs, which results in the lung not being able to expand to the
normal range. This would make gas exchange and inspiration/expiration more difficult.
Different types can include spontaneous (primary or secondary), latrogenic (imbalance
of pressure), traumatic and tension (which impacts on the heart).

2. What are the causes? ( link this back to Bill in the scenario)
The cause of a pneumothorax can be linked towards the type of pneumothorax.
Causes for a spontaneous pneumothorax relates to a weakening of the lining of the
lungs, causing a tear which allows air to enter. A latrogenic is a result of imbalance of
pressure around the lungs and can be caused from medical treatment such as
insertion of lung or pacemaker device. Traumatic pneumothorax can result from a
puncture the lungs, such as a gunshot, stabbing wound or MVA’s. The Tension
pneumothorax is the result of the heart and lungs not working effectively after the other
types of pneumothorax has occurred.
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In Bill’s case, his pneumothorax could be a secondary spontaneous pneumothorax

due to his 40 year history of smoking and his diagnosis of COPD.

3. Management of a patient with Pneumothorax (e.g. ICC)

Management for a pneumothorax, which in Bill’s could be a spontaneous
pneumothorax involves mainly replacement of oxygen, assessment and monitoring
and aspiration of the air contents. Due to Bill’s history of COPD, oxygen therapy would
need to be limited to prevent C02 retention. This could be limited to 2Ls flow rate.
Assessment would involve auscultations of the lung lobes to observe where air may be
entering or escaping from, as well as respiratory assessment. The aspiration of the air
can be performed through an Intercostal catheter aimed at provide an outlet or drain
from the pleural space. The management of the catheter involves the correct
placement which can be assessed through a chest x-ray, while the surround skin and
catheter sight would need to be assessed through skin and pain assessments.

Reference List:
Choi, W. (2014). Pneumothorax. Tuberculosis and Respiratory Diseases, 76(3), 99-
104. doi: 10.4046/trd.2014.76.3.99
Imran, J., & Eastman, A. (2017). Pneumothorax. JAMA, 318(10), 974. Doi:
10.1001/jama.2017.10476

WEEK 2:

Trigger 1: (Josephine)
Where is an ICC inserted for a pneumothorax? And why? What are the potential
complications of an ICC insertion?
When it comes to inserting the intercostal catheter (ICC) it’s important to educate the
patient and to also having the bedhead up to a 45-degree angle with their forearm on
the bed. This will eliminate the risk of any injuries to the other organs.The location
where the ICC is inserted is in the mid-axillary line between the fourth and fifth
intercostal spaces, this stops subdiaphragmatic insertion from occurring. The reason
why the ICC is inserted is for the tubes to help drain fluid, blood or air from the pleural
cavity around the lungs. A chest x-ray should be performed to make sure the ICC is in
the right position. Once the ICC is inserted it is then connected to an underwater seal
drain to test for leakages and drain the fluid.

Some complications of the ICC insertion include;

1. Misplacement of the tube can cause more air to enter the pleural space
2. Tube going into the sub diaphragm, which impact on the spleen, liver or stomach
3. An injury could occur which could damage the heart or lungs. This could be due
to a misplacement of the tube.

References:

Porcel, J. M. (2018). Chest tube drainage of the pleural space: a concise

review for pulmonologists. Tuberculosis and respiratory diseases, 81(2), 106-
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115. doi: https://dx.doi.org/10.4046%2Ftrd.2017.0107

Mao, M., Hughes, R., Papadimos, T. J., & Stawicki, S. P. (2015).

Complications of chest tubes: a focused clinical synopsis. Current opinion in
pulmonary medicine, 21(4), 376-386. doi: 10.1097/MCP.0000000000000169

Arunan, Y., & Roodenburg, B. (2017). Chest trauma. Anaesthesia & Intensive
Care Medicine, 18(8), 390-394.doi: https://doi.org/10.1016/j.mpaic.2017.05.008

Trigger 2: (Bridgette)
What is an underwater seal drain?
A chest drain that is inserted to allow the drainage of pleural spaces from air, blood or
fluid. It prevents backflow of air or fluid back into the pleural spaces.
How does an Underwater seal drain work and its components?
- air leak monitor
- suction monitor
- suction control regulator
- suction port
- positive pressure release valve
- collection chamber
What are the other indications of an Underwater seal drain?
- pneumothorax
- pleural collection
- haemothorax
- post cardiac surgery
- pleural effusion
What does swinging and bubbling in chambers indicate?
Bubbling -intermittent bubbling is normal however lots of bubbles shows there is a leak
within the system
Swinging - intermittent swinging is normal, continuous swinging shows a pressure
change

Trigger 3: (Nav)
What is involved in a comprehensive patient assessment and management?

A comprehensive assessment is a detailed nursing assessment of specific body

system( relating to the presenting problem or other current concern required. This may
involve one or more body system. Nursing staff should utilise their clinical judgement
to determine which elements of a focussed assessment are pertinent for their patient.
Comprehensive assessment can be focused of different systems based of presenting
symptoms of the patient such as Neurological, Respiratory, Cardiovascular, GIT,
Renal, musculoskeletal, Eye, ENT.

Respiratory assessment involves:

History
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● Onset + duration of symptoms cough / shortness of Breath

● Triggers ( dust / aerosol / pollen)

Inspection/Observation
● Observe the overall appearance of the child: alert, orientated,
active/hyperactive/drowsy, irritable.
● Colour(centrally and peripherally): pink, flushed, pale, mottled,
cyanosed , clubbing
● Respiratory rate, rhythm and depth (shallow, normal or deep)
● Respiratory effort (Work of Breathing -WOB): mild, moderate, severe,
inspiratory: expiratory ratio, shortness of breath
● Use of accessory muscles (UOAM):
intercostal/subcostal/suprasternal/supraclavicular/substernal retractions, head
bob, nasal flaring, tracheal tug.
● Symmetry and shape of chest
● Tracheal position
● Audible sounds: vocalisation, wheeze, stridor, grunt, cough -
productive/paroxysmal
● Monitor for oxygen saturation

Auscultation
● Listen for absence /equality of breath sounds
● Auscultate lung fields for bilateral adventitious noises e.g.: wheeze,
crackles, stridor etc.

Palpation
● Bilateral symmetry of chest expansion
● Skin condition – temperature, turgor and moisture
● capillary refill (central/peripheral)
● Fremitus (tactile)
● Subcutaneous emphysema
Cardiovascular assessment involves:
Assessment of the cardiovascular system evaluates the adequacy of cardiac output
and includes.

Inspection:
● Examine circulatory status and hydration status of upper and lower
extremities:
● Colour (central and peripheral): pink, flushed, pale, mottled, cyanosed,
clubbing
● Capillary Refill Time (CRT): brisk (< 2 sec) or sluggish
● Presence of oedema (central and/or peripheral)
● Hydration status: Skin turgor, oral mucosa, and anterior fontanels in
infants
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Palpation:
●Palpate central and peripheral pulses for rate, rhythm and volume
●Skin condition – temperature(peripheral and central), turgor and
diaphoresis

Auscultation:
●Auscultate the apical pulse
●Compare peripheral pulse and apical pulse for consistency (the rate
and rhythm should be similar).
● Auscultate the chest for heart sounds and murmurs

Reference:
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/nursing_assessment/
#Cardiovascular

Trigger 4: (Georgia)
What is the criteria for removal of an ICC?

Trigger 5: (Cody)
What are lung function tests?
Lung function tests (pulmonary function tests) are aimed at assessing the function of
the respiratory system by testing the efficiency. The test involves information on the
capacity of the lungs, the flow rates, gas exchange and volume. The tests can be used
in different situations including assessment pre and post op, assessing effectiveness
of therapies and bronchodilators, diagnosing respiratory disease and for a thorough
assessment of the lungs. The test can be performed using a mouthpiece while
performing deep breathing and exhaling forcefully or as hard the client can go.
The test involves;
- Respiratory rate (BPM)
- Forced vital capacity / FVC (Amount of air which can be exhaled from the lungs
after a maximum effort inhalation)
- Forced expiratory flow at 1 second (FEV 1) – Air volume during the 1 st second of
a exhalation (forced)
- Forced expiratory flow at midpoint of vital capacity (FEF %) – Measurement of
the flowrate 50% into an exhalation
- Tidal volume (Volume exhaled after a normal inhalation)
- Minute ventilation
- Maximal voluntary ventilation
- Maximal inspiratory pressure
- Maximal expiratory pressure
- Peak expiratory flow rate
Are the results for Bill normal?
1. A normal value for FVC (forced vital capacity) would be equivalent to 80% of
predicted, which means Bill’s value is low.
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2. The value refers to the ration between the forced expiratory volume in the 1 st
second of expiration and the forced vital capacity. For a person aged over 50, the
normal value would be above 70%.
3. Post-bronchodilator use is used to determine the effectiveness of the
bronchodilator. For Bill the bronchodilator was effective but does not reach the
normal valued level.

- The ratio is important to determine or diagnose is respiratory dysfunction is due

to a obstructive or restrictive nature
What are the expected results for a pt with COPD?
A lung function test is used for a pt with suspected COPD to determine severity and
limitations of airflow. Levels are tested before and after bronchodilator use, which can
be used to determine how severe limitations could be (partial/reversible).
A FEV1/FVC ratio of less than 70% indicate limitation and is used as the standard for
COPD diagnosis. However, it cannot determine the severity of the disease, but rather
the limitation effect that occurs.

Reference List:
Eisel, S., & Kent, B. (2015). NURSING ASSESSMENT: Respiratory
system. In D. Brown, H. Edwards, L. Seaton & T. Buckley (Eds.),
Lewis’s Medical-Surgical Nursing (pp. 476-499). Chatswood, Australia:
Elsevier Australia
Han, M. K., Dransfield, M., & Martinez, F. (2019). Chronic obstructive
pulmonary disease: Definition, clinical manifestations, diagnosis, and
staging. In H. Hollingsworth (Ed.), UpToDate. Retrieved March 13,
2019, from https://www.uptodate.com/contents/chronic-obstructive-
pulmonary-disease-definition-clinical-manifestations-diagnosis-and-
staging
Maiden, J. (2018). Pulmonary Diagnostic Procedures. In L. Urden, K.
Stacy & M. Lough (Eds.), Critical Care Nursing (pp. 445-455). Maryland
Heights, MO: Elsevier.

WEEK 3:

Trigger 1: (Josie)
What are the normal values of an ABG?

(Rogers & McCutcheon, 2015)

What are the buffering systems?

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In the blood PH, the buffering system is notified when a change in pH levels has
occurred. The main buffering system is sodium–bicarbonate carbonic acid mechanism,
which occurs when a change in pH occurs and the system responds by correcting the
pH levels, however it cannot remove hydrogen ions from the body which could be the
result of the pH differences.

How do we interpret ABG’s?

1. Arterial blood gases are done to determine the PH level, this will let us
know if the patient has high levels of acidosis or alkalosis
2. The paCo2 and sa02 is explored to identify the patient’s oxygen level.
3. The PaC02 and Hc03 is done to distinguish what the causes might
have been to the patient’s respiratory system.
4. If changes occur in the patients C02 or the HC0 the PH level will
change by compensating.

What are the expected results for a pt with COPD?

The following levels which are presented for someone with COPD are;
1. The Sa02 sats will be sitting around 88-92
2. The Pa02 will be around 8.0 kpa
3. The Hc03 is 60 mm hg

References
Rogers, K. M. A., & McCutcheon, K. (2015). Four steps to interpreting arterial blood
gases. Journal of perioperative practice, 25(3), 46-52. doi:
https://doi.org/10.1177%2F175045891502500304

McKeever, T. M., Hearson, G., Housley, G., Reynolds, C., Kinnear, W., Harrison, T.
W., ... & Shaw, D. E. (2016). Using venous blood gas analysis in the assessment of
COPD exacerbations: a prospective cohort study. Thorax, 71(3), 210-215.
doi:http://dx.doi.org/10.1136/thoraxjnl-2015-207573

Trigger 2: (Bridgette)
What is the role of these medications?
Budesonide - corticosteroid - a class of steroid hormone, available as a inhaler,
tablet. Long term action, potent anti-inflammatory properties.

Ipratropium - bronchodilator, dilates airways in the lungs; used in treating symptoms

of cold, asthma, allergies, COPD - due to emphysema, or chronic bronchitis

Salbutamol - short-acting, selective beta2-adrenergic receptor agonist, stimulates

receptors in the lungs called beta2-receptors, that causes the muscles in the airway to
relax and allows the airways to open.

What is a COPD management plan? (What does it incorporate?)

Goals -
- Prevent disease progression
- Relieve symptoms
- Improve exercise tolerance
- Improve health status
- Prevent and treat complications
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- Prevent and treat exacerbation

- Reduce mortality

4 components -
1 - assess and monitor disease
2 - reduce risk factors
3 - manage stable COPD
4-

Trigger 3: (Nav)

What is incentive spirometry?

The purpose of incentive spirometry is to facilitate a sustained slow deep breath.
Incentive spirometry is designed to mimic natural sighing by encouraging patients to
take slow, deep breaths. Incentive spirometry is performed using devices which
provide visual cues to the patients that the desired flow or volume has been achieved.
The basis of incentive spirometry involves having the patient take a sustained,
maximal inspiration (SMI). An SMI is a slow, deep inspiration from the Functional
Residual Capacity up to the total lung capacity, followed by ≥5 seconds breath
hold.

Why is it used for Bill?

Bill has had a chest drain removed and he has COPD. Incentive spirometry reduces
the chances of infection in lungs and post surgery. It also improves lung function in
COPD patients.

Trigger 4: (Georgia)
What are the long-term complications of COPD (+rationalise why)?

Trigger 5: (Cody)
What are the considerations for home oxygen therapy?
● Home oxygen therapy or Domiciliary oxygen therapy is used for clients
who need assistance to maintain their oxygen saturations in the blood, or for
those who require extra oxygen to achieve their maintained levels. Home
oxygen therapy is primarily indicated for people who have an oxygen pressure
level <60 and aim to achieve 60 or >60.
● The therapy can be broken down into different categories for their
purpose, these are continuous (long-term), exertion oxygen (02 levels drop
when the person is active), nocturnal (overnight management) and
emergency/palliative.
● Assessments must be carried out by a consultant to determine if the
oxygen therapy is needed, and if the person is deemed safe to have the
therapy occur in the home. In addition, in order to purchase oxygen equipment
from a supplier the person must provide a certificate from a GP outlining the
oxygen requirements and the indication for the oxygen.
What issues need to be considered for safety/financial?
● Does this person qualify for the oxygen indications? This would include
an oxygen pressure level below 60 and if the person is a C02 retainer who
requires higher levels to trigger a breath.
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● Are the people within the home smokers? Cigarettes and other flame
sources which can cause heat or fire can ignite and increase the burning effect
when combined with oxygen.
● The equipment and oxygen can in some cases be funded through the
government. The costs however could still be expensive in the community,
making it a substantial financial cost if used long-term.
● Travelling with the oxygen will need to be planned correctly through a
GP or provider. The concentrators or cylinders will need to be correctly
prescribed with the appropriate education given. This will ensure the amount of
time for use is correct, if the cylinder can hold enough oxygen for use and if the
battery system can last the required amount.
● Other areas to watch for are practicality of the oxygen cylinders or
therapy. Such as household hazards, pets and children, the ability to transport
with the equipment or move them when needed and if the person is able to
observe signs of irritation and hypoxaemia.
Reference List:
Austin Health. (2014). Domiciliary Oxygen Therapy. Retrieved from
http://www.austin.org.au/Assets/Files/Domiciliary%20Oxygen%20Request.pdf
Department of Health - Ageing and Aged Care. (2017). Oxygen Supplement.
Retrieved from https://agedcare.health.gov.au/aged-care-funding/residential-
care-subsidy/supplements/oxygen-supplementv
Lung Foundation Australia. (2014). Home Oxygen. Retrieved from
https://lungfoundation.com.au/wp-content/uploads/2018/09/Book-Home-
oxygen-booklet-Nov2014.pdf

WEEK 4:

Trigger 1: (Josie)
What is the pathophysiology of Chronic Renal Failure?

What is a kidney function assessment?

- Excrecion
- Maintaining homeostasis
- Regulates blood volume
- Regulates blood iron levels

What is CAPD? What are the Complications?

Trigger 2: (Bridgette)
What are potential complications of poorly controlled diabetes mellitus?
- High blood pressure
- Poor skin integrity
- ulcers
- Diabetic retinopathy - eye sight
- Chronic kidney disease
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- Poor blood supply to extremities

- can lead to ongoing foot and leg issues
- wounds
- Heart disease and stroke
- Narrowing of arteries

Trigger 3: Nav
What is the pathophysiology behind oedema?

Oedema the result of the activation of a series of humoral and neurohumoral

mechanisms that promote sodium and water reabsorption by the kidneys and
expansion of the extracellular fluid. These mechanisms, in concert with
abnormal Starling forces such as increased venous capillary pressure and
decreased plasma oncotic pressure, promote fluid extravasation and edema
formation

What are the normal characteristics of effluent fluid drained from dialysis?
Peritoneal dialysis (PD) effluent is normally transparent. A change in its
appearance may be the first indication of an intra‐ or extraperitoneal abnormality
which may or may not be related to the peritoneal dialysis technique

What is the concern if the appearance in cloudy?

Cloudy dialysate in a PD patient most often reflects an increased number of
polymorphonuclear neutrophils (PMN) in the effluent fluid, and the first
diagnosis to be considered is certainly acute peritonitis. A cell count and a
dialysate culture should be performed urgently. ISPD guidelines recommend
that PD patients presenting with cloudy effluent be presumed to have bacterial
peritonitis and treated as such until the diagnosis can be confirmed or excluded.
If bacterial cultures remain negative despite an increased number of PMN,
atypical infections (mycobacteria, fungi, or parasites) have to be considered and
adequate cultures have to be performed. As reported by Rocklin and Teitelbaum
excessive PMN in PD fluid have also been described in abdominal problems
inducing reactive inflammation, such as splenic infarction, ischemic colitis,
renal cell cancer, pancreatitis, cholecystitis, appendicitis, hernia, small bowel
incarceration, and juxta peritoneal abscess. Abrupt diffuse abdominal pain,
excessive PMN in dialysate effluent, and quick favorable evolution without
antibiotic treatment are suggestive of an intraperitoneal sterile abscess rupture,
usually a remnant of an old peritonitis.
Several cases of neutrophilic peritonitis have been described after
intraperitoneal infusion of vancomycin and seem to be related to the formulation
of the medication. A cloudy appearance of the dialysate can also be related to
accumulation of other components, such as eosinophils, malignant cells, or
triglycerides

Trigger 4: (Georgia)

When bacteria enters the normally sterile bloodstream, they can be widely and easily
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spread throughout the body. The bacteria will trigger a systemic inflammatory
response - this is called sepsis. Sepsis can lead to a hypotensive state and cause poor
tissue perfusion, which in turn can cause organ failure (this is called septic shock)

What are the clinical manifestations of sepsis?

Fever, hypotension, reduced cardiac output, blood clots (Bullock and Hales, 2019)

What are the normal ranges of the blood tests?

Expected values?

Trigger 5: (Cody)
Why is combination AB therapy prescribed?
- Broad spectrum to narrow down which AB is the most effective, or
to determine where an infection originates. Treatment of sepsis with 3
different antibiotics
What are the adverse effects and precautions for these AB’s) + Relate to
Peggy’s conditions?
- Toxicity (Vancamycin/gentamycin)
- Nephrotoxicity (Due to kidney excretion)
- Antibiotic resistance

WEEK 5:

Trigger 1: (Josie)
- What are the physiological complications for diabetic patients who need
to fast for theatre?
Diabetes management is a concern during surgery due to glycaemic control. The
levels are impacted by anaesthesia, postoperative complications (sepsis, nutritional
status) and they are at a higher risk of surgery cardiovascular complications.
During surgery anaesthesia can impact on glucagon hormones, insulin resistance,
insulin secretion which can lead to hyperglycaemia or ketoacidosis.
Fasting prior to surgery reducing the risk of hyperglycaemia responses during the
surgery as due to a low caloric intake.
Diabetics can be as risk of hypoglycaemia prior to surgery when fasting,
glucose/dextrose alongside potential insulin can be used to provide a balanced blood
glucose levels.
Reference
Khan, N., Ghali, W., & Cagliero, E. (2018). Perioperative management of blood
glucose in adults with diabetes mellitus. In J. Mulder (Ed.), UpToDate.
Retrieved from https://www.uptodate.com/contents/perioperative-management-
of-blood-glucose-in-adults-with-diabetes-mellitus

Trigger 2: (VAC dressings)

a. (Bridgette)
What is a VAC dressing?
Negative pressure wound therapy,
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- draws moisture and excess fluid from the wound

- removes exudate
-
How does it work?
- air tight
- foam placed within the wound
- promotes wound healing from the wound bed outwards

Complication:
Hemorrhage
Infection
Skin breakdown
pain
b. (Nav)
- What are the advantages and disadvantages?
Benefits
1. Reduced morbidity
2. Decreases hospital costs
3. simplifies dressings, reduces number of dressings
4. decreases duration of hospitalisation
5. Enclosed wound environment and chances of infection
decreased.

Disadvantages
1. May be painful especially intermittent cycle
2. May delay referral for appropriate/definitive surgery
3. Pain , attached to equipment needed electrical source to work.

- What are the contraindications?

Contraindications
1. Cancer
2. Necrotic tissue
3. Fistula
4. Active bleeding
5. Wound malignancy, untreated osteomyelitis, direct contact with
exposed blood vessels.
-
Trigger 3: (Cody)
Why is fentanyl being given?
● Opioid analgesia
● Indicated for pain relief, can be used during general and regional
anaesthesia and as a pre-operative medication
● Long acting as a patch - 72 hours, IV, tablets, sublingual tablets, nasal
spray, soluble film

What are the pharmacodynamics/pharmacokinetics?

● Mode of action (Acts through the CNS by binding to opioid receptors
and decreased stimuli from the sensory nerve endings, decreasing pain
pathways
● Can be absorbed through the skin/topical, Intramuscular, and GI tract
NRSG353 - Acute Care Nursing 2

● Travels through the body with 80-85% protein binding

● Metabolised within the liver, and excreted by bile in the liver

Peggy cannot have morphine as morphine is excreted via kidneys and she has kidney
failure.
References:
Kizor, R., & Hodgson, K. (2018). F. In R. Kizor & K. Hodgson (Eds.),
Saunders Nursing Drug Handbook (pp. 463-510). St. Louis, MO:
Elsevier.
Australian Medicines Handbook. (2019). Fentanyl. Retrieved from
https://amhonline-amh-net-au.ezproxy1.acu.edu.au/chapters/analgesics
/drugs-pain-relief/opioid-analgesics/fentanyl#fentanyl-opioid-analgesics-
modeaction

Week 6:

Trigger 1: (Josie)
What is the likely cause of these signs and symptoms?
-Anxiety
-AMI
Christopher is experiencing crushing substernal pain, this particular symptom could be
indicating that Christopher is having chest pain or angina, which could lead into
myocardial ischemia or an infarction. The way to diagnose what the cause may be, he
could have an ECG performed and a blood test looking for troponin.
What is the pathophysiology of these potential causes?
A myocardial infarct occurs when there is a build up of atherosclerosis in the
endothelium cell within the coronary artery. When this happens, it causes the blood
flow to become restricted due to the increase of plaque. When there is an increase in
plaque, it causes thrombogenic to form, causing platelets to be released, which
produces the coagulation state. Resulting in vessels to become blocked, reducing
normal blood flow. If this occurs, it can lead to necrosis in the cardiac muscle cell due
to reduced blood flow and haemoglobin. In order to determine the severity of how
serious this is, an assessment must be done to check the myocardium supply. This is
done to see if the vessel was fully or partially blocked.

When an myocardial infarction happens, it is categorised as either a STEMI or

NSTEMI.

References:

https://www.annemergmed.com/article/S0196-0644(15)00119-5/abstract
http://prueba.aphem.com.mx/doctos/Aproach_to_the_patient_with%20chest_pain.pdf

Trigger 2: (Bridgette)

What is the significance of these results?

NRSG353 - Acute Care Nursing 2

ECG - ST depression
- ischemic muscle
- partial occlusion
- post heart attack if the tissue does not recover can show as this
Troponin I - levels elevated
- troponin T & troponin I - blocked vessels will release this
- CK-MB - when tissue is damaged
- elevated troponin myocardial cellular death has occured
Cholesterol - 9.1 mmol/L. (too high)
-
HbA 1C - 0.09
- unmanaged / poorly managed blood glucose levels which can increase the risk of
microvascular disease

Trigger 3: (Nav)
Why have these interventions been ordered? What is the goal of management?

Trigger 4: (Georgia)
What is angina and the pathophysiology of this?
Angina is a condition in which the heart cells experience a temporary ischaemic
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state (Bullock and Hales, 2019)

What are the signs and symptoms?

Stable Angina: Chest pain

Unstable Angina: Chest pain, nausea, shortness of breath, sweating and vomiting

(Bullock and Hales, 2019)

Trigger 5: (Cody)
What is a NSTEMI?
An NSTEMI (Non-ST segment elevation myocardial infarct) is a type of heart attack
where a blockage has occurred with blood flow to the heart but has been temporary or
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not a complete blockage. The can result in damage to the muscle of the heart and
myocardial ischaemia to occur. The process can be assessed or observed through an
ECG where the ST segment is depressed or not elevated.
What are the common risk factors?
Risk factors for a myocardial infarct share similar factors for coronary artery disease
even at an earlier age.
Risk factors overall for AMI’s involved:

● Diabetes
● Hypertension
● Obesity
● Atrial fibrillation
● Dyslipidaemia
● Atherosclerosis (including angina, strokes, PVD)
● Aged 65+

What is coronary artery disease?

Coronary artery disease is a condition which is characterised by narrowing of the
coronary arteries to the heart and the restriction of blood flow. Inside the arteries, over
time plaque can build up which can be a result of cholesterol and lipids, leading to
major complications including angina and acute myocardial infarct.

Reference List:
Cleveland Clinic. (2019). CAD: Acute Coronary Syndrome. Retrieved from
https://my.clevelandclinic.org/health/diseases/16713-cad-acute-coronary-syndrome
BMJ. (2018). Non-ST-elevation myocardial infarction. Retrieved from
https://bestpractice.bmj.com/topics/en-us/151/history-exam#riskFactors
Heart Foundation. (2019). What is coronary heart disease?. Retrieved from
https://www.heartfoundation.org.au/your-heart/heart-conditions/what-is-coronary-heart-
disease

Week 7:

Trigger 1: (Josephine)

What is AF?
Atrial fibrillation is known as an irregular heart beat / rhythm. In AF the signals that go
to your heart become uncontrolled which can lead into AF. This is due to the
disorganised signals that begin in the SA nodes, which causes the AF to start. With
AF, blood does not always pump to the heart sufficiently.

What are the causes and risks of AF?

NRSG353 - Acute Care Nursing 2

There a number of causes which can affect the heart and lead into AF. Some of these
are known as the following;
1. Heart failure
2. High blood pressure
3. Heart attack
4. Chronic obstructive pulmonary disease

References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4759971/m

https://jamanetwork.com/journals/jama/fullarticle/2190988

Trigger 2: (Bridgette)
What are the patho effects of AF on the body?

Reduced ventricular filling = smaller stroke volume

AF causes a loss in AV synchrony → atrial kick is lost → irregular palpations
& symptoms of heart failure ie. shortness of breath, fatigue, exercise
intolerance
May be symptomatic or experience significant chest pain

Tachy-arrhythmia → uncoordinated atrial activation with consequences

The Av node cannot filter fast, chaotic, irregular (often from multiple areas)
→ inadequate emptying of atria
Ventricular rate may increase due to excess number of signals passing
through AV node → increased ventricular activity (heart beat) to >60-100
Not sustainable → circulation of blood reduced = light headedness, fatigue,
breathlessness, chest pain

Trigger 3: (Nav)
What are arrhythmic drugs and the common class?

What are the nursing implications for giving arrhythmic drugs?

Trigger 4: (Georgia)
What is central venous line?
CVADs are vascular access devices where the distal tip of the catheter is
located in the central venous circulation and can remain insitu for weeks to
years (Camp-Sorrell, 2010).
What are the common sites of insertion? What is the prefered site?
Larger veins in the upper arm, neck or chest - catheter tip sits in the central
circulation, at cavoatrial junction – lower 1/3rd of superior vena cava where
blood flow is approximately 2000mls / min (Canadian Vascular Access
Association, 2013; Nichols & Humphrey, 2008)

Avoidance of femoral vein - due to risk of infection as this is considered a “dirty

area” (Infusion Nursing Society, 2011; Loveday et al., 2014; O'Grady et al.,
2011)
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What are the complications?

local skin irritations
cellulitis
thrombosis
infection – local or systemic
premature removal related to catheter migration and loss of patency
catheter rupture
pneumothorax
air embolism
pinch off syndrome

Trigger 5: (Cody)
What is an angiogram and why is it indicated?

● Procedure where contrast is injected into the veins and as it travels

throughout the body a series of x-rays follow along to see when clots,
blockages and flow of blood vessels may be.
● Used for diagnosis and extent of injury in coronary artery disease,
myocardial infarct, trauma (arteries), peripheral vascular disease
● For coronary artery disease, a coronary angiogram is used to assess
how significant the disease progression is at that time. It allows for testing of
perfusion and narrowing of coronary arteries and cardiac muscles. Should
ensure the medical team has enough information to determine how effective
treatment has been and what further interventions should be considered.

What is continuous cardiac monitoring and how does it differ to an ECG?

The cardiac monitoring refers to a continuous measurement of cardiac function by
detecting arrhythmias, heart rate and rhythm, QRST interval and segments. They can
also include oxygen saturations or attachable blood pressure cuffs for intermittent
monitoring.
The monitoring can involve between 3 - 15 leads, which depend on the indication for
the monitoring. Indicated for - post myocardial infarct if at immediate further risk,
suspected or haemodynamically compromising arrhythmias, electrolyte imbalances,
following interventions to coronary arteries and cardiac surgery
Cardiac monitoring differs from an ECG as the ECG would be a snap shot/reading for
the duration of the recording. Continuous cardiac monitoring is a live reading of the
activity rather than recording the activity.

Gerber, T., & Manning, W. (2018). Noninvasive coronary imaging with

cardiac computer tomography and cardiovascular magnetic resonance.
In B. Downey and S. Lee (Eds.), UpToDate. Retrieved from
https://www.uptodate.com/contents/noninvasive-coronary-imaging-with-
cardiac-computed-tomography-and-cardiovascular-magnetic-resonance

Hannibal, G. B. (2014). Cardiac Monitoring and Electrode Placement

Revisited. AACN Advanced Critical Care, 25(2), 188-192. doi:
10.1097/NCI.0000000000000020
Zègre-Hemsey, J., Garvey, J., & Carey, M. (2016). Cardiac Monitoring
in the Emergency Department. Critical Care Nursing Clinics of North
NRSG353 - Acute Care Nursing 2

America, 28(3), 331-345. doi: 10.1016/j.cnc.2016.04.009

Week 8:
Trigger 1: (Josephine)
What is the causes of his symptoms?

Amiodarone is known as an antiarrhythmic agent, it is used to help manage and treat

tachyarrhythmia that may occur in a patient. Amiodarone may affect the central nervous system
by causing some side effects. The following are;
1. Headaches
2. Vertigo
3. Fatigue
4. Dizziness

Since Mr Taylor is presenting with signs and symptoms of dizziness and feeling light headed.
Some of the nursing considerations should be followed to assess the cause of his symptoms.
Such as:

1. Is the infusing dose of amiodarone correct and is it causing him to get these side effects?
The infusion has achieved a sinus rhythm so should it be ceased

2. Has his high blood pressure or heart rate dropped while this infusion was running?
Indicating the medication is passed the therapeutic effect

Mims Australia. (2019) Amiodarone GH injection. Retrieved from https://www-mimsonline-

com-au.ezproxy1.acu.edu.au/Search/FullPI.aspx?ModuleName=Product
%20Info&searchKeyword=amiodarone&PreviousPage=~/Search/
QuickSearch.aspx&SearchType=&ID=123950001_2

Trigger 2: (Bridgette)
Who is the MET team associated?
- ICU registrar / consultant
- ICU nurse
- ED registrar / consultant
- ED nurse
- Specialty registrar / consultant

What is the criteria for issuing a met call?

Blood pressure - < 90
Pulse - >140 or <40
Resp rate - >32 or <7-9
What interventions can an RN initiate in a MET call?
- scribe
- Runner
- CPR
-
NRSG353 - Acute Care Nursing 2

Trigger 3: (Nav)
What is gelofusion and how does it work?
Gelofusine is a 4% w/v solution of succinylated gelatine (also known as
modified fluid gelatine) used as an intravenous colloid, and behaves much like
blood filled with albumins. As a result, it causes an increase in blood volume,
blood flow, cardiac output, and oxygen transportation.

What is VF and the causes?

VF:
Ventricular fibrillation is a heart rhythm problem that occurs when the heart
beats with rapid, erratic electrical impulses. This causes pumping chambers in
your heart (the ventricles) to quiver uselessly, instead of pumping blood.
Sometimes triggered by a heart attack, ventricular fibrillation causes your blood
pressure to plummet, cutting off blood supply to your vital organs.

Ventricular fibrillation, an emergency that requires immediate medical attention,

causes the person to collapse within seconds. It is the most frequent cause of
sudden cardiac death. Emergency treatment includes cardiopulmonary
resuscitation (CPR) and shocks to the heart with a device called an automated
external defibrillator (AED).

Causes:
The cause of ventricular fibrillation isn't always known. The most common
cause is a problem in the electrical impulses traveling through your heart after
a first heart attack or problems resulting from a scar in your heart's muscle
tissue from a previous heart attack.

Some cases of ventricular fibrillation begin as a rapid heartbeat called

ventricular tachycardia (VT). This rapid but regular beating of the heart is
caused by abnormal electrical impulses that start in the ventricles.

Most VT occurs in people with a heart-related problem, such as scars or

damage from a heart attack. Sometimes VT can last less than 30 seconds
(nonsustained) and may not cause symptoms. But VT may be a sign of more-
serious heart problems.

If VT lasts more than 30 seconds, it will usually lead to palpitations, dizziness

or fainting. Untreated VT will often lead to ventricular fibrillation.

Most cases of ventricular fibrillation are linked to some form of heart disease.
NRSG353 - Acute Care Nursing 2

Trigger 4: (Georgia)
What is the role of adrenaline in CA? what is the dosage and the effects?

Trigger 5: (Cody)
What are the 4 H’s and 4 T’s (for treatable causes)?
The 4H’s and 4T’s refer to different treatable or reversible causes that contribute
towards cardiac arrest. The aim is to learn the causes when performing CPR and
basic life support. It can improve the health outcomes involved by treating the cause
while resuscitating.
4H’s:
1. Hypoxia
2. Hypo/hyper kalaemia
3. Hypo/hyper thermia
4. Hypovolaemia
4T’s:
1. Tension pneumothorax
2. Tamponade
3. Thrombosis
4. Toxins
What is COACHED?
COACHED is an acronym used to manage defibrillation during advanced life support
to improve teamwork and cohesion during the difficult situations. Also allows for safety
to be maximised when the defib is charging and providing a shock. The acronym
stands for:
C – Continue compressions
O – Oxygen away
A – All others away
C – Charging
H – Hands off
E – Evaluate
D – Defibrillate or disarm
Coggins, A., Nottingham, C., Chin, M., Warburton, S., Han, M., Murphy,
M., . . . Moore, N. (2018). A prospective evaluation of the
'C.O.A.C.H.E.D.' cognitive aid for emergency defibrillation. Australasian
Emergency Care, 21(3), 81-86. doi: 10.1016/j.auec.2018.08.002
Durila, M. (2018). Reversible causes of cardiac arrest 4 “Ts” and 4 “Hs”
can be easily diagnosed and remembered following general ABC rule,
Motol University Hospital approach. Resuscitation, 126, E7. doi:
10.1016/j.resuscitation.2018.03.013