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Critical Care
Intensive care
High Dependency Unit
Progressive Care Unit
Outreach Care
Immediate priority
Preserve life
Prevent, reverse or minimize
damage to vital organs
Achieved by optimizing
cardiovascular and respiratory
function to maximize oxygen to
tissues
Heart rate
Blood pressure
Respiratory rate
Pulse oximetry
Hourly urine output
Temperature
Blood gases
Patient is connected to
appropriate monitoring and
support equipment, and critical
medications are administered
Prearrival Assessment
The charge nurse notifies Sue
that she will be receiving a 26-year old
man from the ER who was involved in
a serious car accident. The ED nurse
caring for the patient has called to
give Sue a report. The patient suffered
a closed head injury and chest trauma
with collapsed left lung. The patient
was intubated and placed in a
mechanical ventilator. IV access had
been obtained, and a left chest tube
had been inserted. After obtaining a
computed tomographic (CT) scan of
the head, the patient will be
transferred to the ICU. Sue questions
the ED nurse whether the patient has
been agitated, had a foley catheter
placed, and whether family had been
notified of the accident.
Sue goes to check the
patients room prior to admission and
begins to do a mental check of what
will be needed. The patient is
intubated so Ill connect the AMBU bag
to the oxygen source, check for
suction catheters, and make sure that
suction systems are working. The
pulse oximetry and the ventilator are
ready to go. I have an extra suction
gauge to connect the chest tube
system. Ill also turn in the ECG
monitor and have the ECG electrodes
ready to apply. The arterial line flush
system and transducer are also ready
AdmissionThe
Quick
Check
to B.
be connected.
IV infusion
devices
are
set
up.
This
patient
has an
Assessment
altered
LOC,
which
means
frequent
- Obtained immediately after
neuro checks and potential insertion of
arrival
Quick overview of the adequacy
of ventilation and perfusion to
ensure early intervention for any
life threatening situation
Appearance (consciousness)
Airway
Breathing
Circulation and cerebral
perfusion, chief complaints
Drugs
Equipment
General Appearance
(Consciousness)
Behavior
Airway
Patency
Having the patient speak
Airway
-
Breathing
-
Chief Complaint
-
Palpating a pulse
ECG viewing (HR, rhythm, ectopy)
BP and temperature
Peripheral perfusion and capillary
refill
Skin color, temperature, moisture
Presence of bleeding
Level of consciousness,
responsiveness
IV access initiated
Ongoing IV infusions checked
Verify correct infusion of the
desired dosage and rate
Chief Complaint
-
Comprehensive Assessment
-
Allergies
Comprehensive Admission Assessment
-
Initial treatment
-
HR
BP
RR
Temperature
Hourly UO
Pulse oximetry
ABG
Respiratory system
History
Dyspnea
Chest pain
Sputum production
Cough
Health History
-
Inspection
Cyanosis
Breathing
Increase AP diameter of chest
Chest deformities and scars
Patients posture
Position of the trachea
RR
Depth of respiration
Inspection
Duration of inspiration vs.
duration of expiration
o Observation of general
chest expansion
Palpation
Tactile fremitus
Assess subcutaneous emphysema
PERCussion
Assess for dullness and
hyperresonance
o
Nervous
1.
2.
3.
4.
5.
6.
Cardiovascular
1.
2.
3.
4.
5.
Respiratory
1.
2.
3.
4.
Renal
1.
2.
3.
Gastrointestinal
1.
2.
3.
4.
5.
6.
Integumentary
1.
Endocrine
1.
Social History
-
Age, gender
Ethnic origin
Height, weight
Highest educational level
completed
Occupation
Marital status
Primary family members/significant
others
Religious affiliation
Advance directive and durable
power of attorney for health care
Substance abuse (alcohol, drugs,
caffeine, tobacco)
Domestic abuse or vulnerable adult
screen
Psychosocial Assessment
-
General communication
Coping styles
Anxiety and stress
Expectations of critical care unit
Current stresses
Family needs
Spirituality
-
Faith/spiritual preference
Healing practices
Physical assessment
-
Nervous system
Cardiovascular system
Respiratory system
Renal system
Gastrointestinal system
Endocrine, hematologic, and
immune systems
Integumentary system
Hematologic
Do you have any problems with chronic
infections?
Immunologic
Have you recently been exposed to a
contagious illness?
Psychosocial
Do you have any physical conditions which
make communication difficult (hearing loss,
visual disturbances, language barriers, etc)?
Sample Questions
Auscultation
-
Vesicular
Bronchovesicular
Bronchial
Tracheal
Egophony
Whispered pectoriloquy
Auscultation pattern
+4 = depression in tissue
disappears in > or = 4seconds
2.
Assess
patients
usual
sleeping
patterns
Minimize effects of underlying disease
process as much as possible (eg
reduce
fever,
eliminate
pain,
minimize metabolic disturbances)
Integumentary
-
Pain/discomfort
-
Psychosocial
-
4.
2.
3.
-
Illness
Metabolic changed
Underlying diseases (eg cardiovascular
disease, chronic obstructive pulmonary
disease (COPD)
Pain
Anxiety, dear
Delirium
Medications
Beta-blockers
Bronchodilators
Benzodiazepines
Narcotics
Environment
Noise
Staff conversations
Television/radio
Equipment alarms
Frequent care interruptions
Lightning
Lack of usual bedtime routine
Room temperatrure
extremities
Infection examples
when
used
Cardiovascular
Gastrointestinal
Mechanical
Mechanical Ventilators
Goals of Mechanical Ventilation:
-
Reversal of hypoxemia
Reversal of acute respiratory
acidosis
Relief of respiratory distress
Prevention or reversal of
atelectasis
Resting of ventilator muscles
Decrease in systemic or
myocardial oxygen consumption
Reduction of ICP
Stabilization of chest wall
Iron Lung
Positive Pressure Ventilators
-
Pressure-cycled
Time-cycled
Volume-cycled
Pressure-Cycled
-
Time-Cycled
-
Volume-cycled
-
Requires paralysis
Monitor for auto-PEEP,
barotrauma, hemodynamic
instability
Ventilator Controls
-
FiO2
Initially patients will be on 60%
Changes in FiO2 is based on ABG,
or to maintain SaO2 >90%
Risk for Oxygen toxicity when
FiO2 is > 60% for 12 to 24 hours
Tidal Volume
-
10
8-10ml/kg
Respiratory rate
-
Frequency
Number of breaths per minute
Respiratory rate
-
Pressure Limit
-
PEEP
-
PEEP
-
PEEP
-
Barotrauma
Sensitivity
-
Sensitivity
-
Alarms
-
Alarms
-
High pressure
Decreased compliance
Kinks in the tubing
Patient biting the tube
Secretions
Patient-ventilator asynchrony
Aspiration
Ventilator malfunction
Barotrauma
Decreased cardiac output
Water imbalance
Immobility
GI problems
Oxygenation/Ventilation
-
11
Skin Integrity
-
Nutrition
-
Psychosocial
-
Interventions
-
Teaching/Discharge Planning
-
Interventions
-
PEEP
Medications for Ventilated Patients
Sedative
-
Midazolam, Propofol
Paralytic
-
Atracium, rocuronium,
succinylcholine
Opioids
12
Morphine, fentanyl
Renal System
Renal support
-
Urine volume
Fluid balance
Renal concentrating power
Acid-base balance
Rate of rise of BUN, creatinine,
and potassium concentrations
Oliguria (<0.5mL/kg/h)
Life threatening hyperkalemia
(>6mmol/l) resistant to drug
treatment
Rising plasma concentrations of
urea or creatinine, or both
Severe metabolic acidosis
Symptoms related to uremia
(pericarditis, encephalopathy)
Serum
Urine
Reference interval varies with
race, ethnicity and gender
sequelae of neurological
impairment may lead to patient
requiring intensive care
loss of consciousness may lead to
obstruction of airways, loss of
protective airway reflexes, and
disordered ventilation that
requires intubation or
tracheostomy and mechanical
ventilation
airway obstruction
absent gag or cough reflex
measurement of ICP and cerebral
perfusion pressure
raised ICP requiring treatment
prolonged or recurrent seizures
which are resistant to
conventional anticonvulsants
hypoxemia
hypercapnia or hypocapnia
Nervous System
-
Creatinine
-
Neurological System
Alert: Normal
Awake: may sleep more than
usual or be somewhat confused
13
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Muscle strength
-
Pain stimulus
Central stimulus
Peripheral stimulus
-
State of wakefulness
Reflects function of reticular
activating system and brainstem
Decerebrate or decorticate
Neurological history
Recent trauma that could affect
the nervous system
Recent infections (sinusitis or ear
infections)
Feeling of dizziness, loss of
balance, black-out spells
Clumsiness or weakness of
extremities
Neurological history
-
Alcohol
Epilepsy
Insulin
Overdose/oxygenation
Underdose/uremia
Trauma
Infection
Psychosis
Stroke/shock
Circulatory Support
-
Awareness
-
Pupils
Shape
Size and reaction
Symmetry
Corneal reflex
Cranial nerves V and VII
Protective reflex
Brainstem function
Gag reflex and ability to swallow
Cough reflex controlled by cranial
nerves IX and X
Circulatory support
-
14
Cardiovascular system
-
Pulse pressure
Color and temperature of skin
Nail color and capillary refill
ECG waveform
P wave: atrial depolarization
QRS complex: ventricular repolarization
T wave: ventricular repolarization
U wave: repolarization of the papillary
muscles or Purkinje fibers
PR interval
-
Peripheral pulse
-
Doppler ultrasound
Pulse deficit
-
Cardiac History
-
Chest pain
Dyspnea
Edema of feet/ankles
Palpitations/syncope
Cough and hemoptysis
Nocturia
Cyanosis
Intermittent claudication
Paroxysmal Supraventricular
Tachycardia (PSVT)
Defibrillation and Cardioversion
-
Monophasic defibrillators
-
Biphasic Defibrillators
-
Safety
-
Cardiac dysrhythmias
Electrocardiogram
QT Interval
Peripheral Pulse
-
Relaxation
Defibrillation
-
15
Cardioversion
-
Useful in:
Unstable VT with pulse
Supraventricular tachycardia
Atrial flutter
Atrial fibrillation
When patient becomes unstable
or does not convert to normal
rhythm with pharmacological
agents
Cardioversion
-
Cardioversion
-
Cardioversion
-
Pacemakers
-
CVP catheter
CVP catheter
-
Pressure transducer
-
Complications of CVP
Infection
Thrombosis
Air embolism
Swan-Ganz Catheter
Swan-Ganz Complications
-
Infection
Pneumothorax
Ventricular dysrhythmias
Pulmonary artery rupture
Length of insertion should be
noted
Swan-Ganz Catheter
16
Hemodynamic monitoring
Cardiac output
Stroke volume
Mean arterial pressure
Systemic vascular resistance
Pulmonary vascular resistance
Cardiac output
-
Stoke volume
-
Stroke volume
-
Preload
-
Preload
-
Afterload
-
Pulmonary hypertension
Pulmonary edema
Cardiac output
-
155-255 dynes.sec/cm5
Vasoconstriction
Hypothermia
Vasodilation
Hyperthermia
Sepsis
Contractility
-
Vasoactive Agents
Evidence-based practice: Bedside Cardiac
Monitoring for Arrhythmia Detection
Electrode Application
o Make sure skin is clean and dry before
applying monitoring
17
Reference:
Chulay, M., Burns, S. 2010. AACN
Essentials
of Critical Care
Nursing Second
Edition. The
McGraw-Hill Companies, Inc.