The document discusses the roles and responsibilities of critical care nurses in caring for critically ill patients. It covers facilitating communication between healthcare providers, patients, and families; ensuring patient safety; and respecting patients' autonomy, beneficence, non-maleficence, veracity, and fidelity in decision making. It also addresses educating patients and families, managing common critical illnesses like myocardial infarction and heart failure, and the nursing care involved.
The document discusses the roles and responsibilities of critical care nurses in caring for critically ill patients. It covers facilitating communication between healthcare providers, patients, and families; ensuring patient safety; and respecting patients' autonomy, beneficence, non-maleficence, veracity, and fidelity in decision making. It also addresses educating patients and families, managing common critical illnesses like myocardial infarction and heart failure, and the nursing care involved.
The document discusses the roles and responsibilities of critical care nurses in caring for critically ill patients. It covers facilitating communication between healthcare providers, patients, and families; ensuring patient safety; and respecting patients' autonomy, beneficence, non-maleficence, veracity, and fidelity in decision making. It also addresses educating patients and families, managing common critical illnesses like myocardial infarction and heart failure, and the nursing care involved.
The document discusses the roles and responsibilities of critical care nurses in caring for critically ill patients. It covers facilitating communication between healthcare providers, patients, and families; ensuring patient safety; and respecting patients' autonomy, beneficence, non-maleficence, veracity, and fidelity in decision making. It also addresses educating patients and families, managing common critical illnesses like myocardial infarction and heart failure, and the nursing care involved.
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The key takeaways from the document are the roles of critical care nurses, common ethical issues they may face, important patient education aspects, and common drugs used in ICU.
The roles of a critical care nurse include providing direct patient care, involving family members, facilitating communication, ensuring patient safety, and formulating patient care goals.
Common ethical issues faced include patient autonomy, beneficence, non-maleficence, veracity, fidelity, and justice.
CARING FOR CRITICALLY ILL PATIENT
Role of a Critical Care Nurse
Provide care direct to the patient. Involve family members in patients care. Facilitate communication among healthcare provider, patient, and family. Provide appropriate intervention & actions. Formulate patient care goals. Ensure patient safety: Identify patient correctly Improve communication among staffs. Use medication safely. Prevent infection. Identify patient safety risks Prevent mistakes in surgery.
ETHICAL & LEGAL ISSUES
Autonomy Freedom to make decision without others interference. Critical care nurse act as patient advocate before patient and family make decision: Provide information Clarify points Reinforce information Provide support
Beneficence Promote wellbeing by considering harms and benefits, leading to positive outcome.
Non-maleficence Prevent harm and correct harmful situation.
Veracity Truth telling in information given. Important in requesting informed consent because patient need to be aware about the risks and benefits.
Fidelity Requires loyalty, fairness, truthfulness, advocacy, and dedication
Justice Refers to an equal and fair distribution of resources, based on analysis of benefits and burdens of decision.
Elements in Code of Ethics The professional code of ethics Values and relationship among members of the profession and society. The purpose of the profession The need of profession to provide certain duties formed between nursing and society The standards of practice of the professional Describe specifics of practice in variety of settings and subspecialties.
Steps in ethical decision making - Identify the health problem - Define the ethical issue - Gather additional information - Outline the decision maker - Examine ethical & moral principles - Explore alternative options - Implement decisions - Evaluate & modify actions Legal Relationships Nurses duty Nurse-employer Competent & able to follow policies and procedures. Nurse-patient Give reasonable and careful care Nurse-law Provide safe and competent practice as defined by the standard
Patient Care Issues Consent must be voluntary and informed Person giving consent must be: Legally competent Adult Mentally stable Have capacity (reasoning) Patient can refuse treatment. If patient is not for resuscitation, DNR order should be documented by doctor. The doctor should explain everything to the patient about diagnosis and treatment.
PATIENT & FAMILY EDUCATION
Nurses responsibility Assess patient & family learning needs. Education must be ongoing, interactive, and consistent with the education level. Reduce stress, anxiety, and fear first. Focus on orientation of environment & equipment, procedure explanation, and immediate plan of care. Ensure patient is emotionally stable.
Learning Needs Orientation of various care providers & services available. Orientation on environment (eg: call bell) Orientation on unit rutines and care plan (visiting hour, monitoring, daily weight) Explanation on equipments, monitors & associates alarms (eg: ventilator) Explanation on procedures & expected outcomes. Information on medication (name, indication, side effects) and reporting to nurse. Immediate plan of care Transition to next level of care: transferring, staffs, environment Discharge plan (medication, diet, activity)
Successful Education - Attention The information must be important to know. - Simple Use everyday language & avoid medical terms - Time Be present when teaching. - Reinforce Provide positive rewards to patient.
Special Consideration for: 1. Older adult 2. Sedated or unconscious patient 3. Illiterate patient 4. Noncompliant patient MYOCARDIAL INFARCTION (MI)
Definition: Irreversible myocardial necrosis due to sudden decrease or total stop of coronary blood flow to a specific area of myocardium.
Pathophysiology
Clinical Manifestation Chest pain squeezing in nature radiating to left arm, jaw or upper back Shortness of breath Nausea & vomiting Heartburn Sweating General malaise STEMI/ NSTEMI
Risk Factors Hyperlipidemia Diabetes Smoking Male Family history Obesity
Types of MI
Cholesterol deposited on artery wall forming plagues and causes it to harden and narrows the lumen. The plagues may rupture and blood clot form on the surface of the plague. The clot blocks the blood flow and causes MI. Oxygen delivery is affected and cause due to the thrombosis or spasm close to the rupture plague Anterior MI Occlusion of proximal left anterior descending artery ST-elevation in lead V1-V4 Most dangerous MI Left Lateral MI Occlusion of circumflex coronary artery New Q waves & ST-elevation in leads I, aVL. V5, V6 Inferior MI Occlusion of right coronary artery Distiurb blood supply to SA & AV nodes, and Bundle of His (proximal part) High mortality if Rt ventricle affected. Right Ventricular MI Occlusion of the proximal part of Rt coronary artery Can affect right ventricle and inferior wall Posterior MI Occlusion in Rt coronary artery or circumflex artery Tall R waves can be seen in leads V1, V2 Diagnostic Test I. 12-lead ECG ST-segment (elevated/ not elevated) If NSTEMI, necrosis is not full thickness Q wave present II. Cardiac enzyme or biomarkers CK-MB (rise 3-12 hrs, peak at 24 hrs, remain elevated for 2-3 days) Trop-I (rise 3-12 hrs, peak at 24 hrs, remain elevated for 2-3 days) Trop-T (rise 3-12 hrs, peak at 12-48 hrs, remain elevated 5-14 days) III. Chest X-ray
Treatment a) Reopening of the coronary artery -Fibrinolytic therapy -Percutaneous Catheter Intervention (PCI) b) Anticoagulation -IV Heparin bolus with fibrinolytic therapy c) Pain control -SL Nitroglycerin 1 tab (0.04mg) every 5 mins -IV Morphine 2-4mg -Non-coated Aspirin 162-325mg -Oxygen therapy maintain >90% d) Dysrhythmias prevention -IV Amiodarone -Beta blocker reduce heart rate e) Glucose control f) Prevention of ventricular remodelling -ACE inhibitor/ ARB reduce risk of heart failure
Complications of MI ^ Related to electrical dysfunction New murmur Bradycardia Bundle branch block Heart block ^ Related to contractility Heart failure Pulmonary edema Cardiogenic shock
Nursing Management Preventing complication -Manage and alleviate chest pain -Assess and reduce anxiety -Monitor lab result (esp. K and Mg to prevent arrhythmia) -Monitor ST-segment continuously -Monitor signs of arrhythmia -Monitor arterial oxygen saturation -Create plan for patients physical activity -Assess signs of heart failure (pedal edema) -Assess heart sound for new murmur. -Monitor patient for drug compliance -Give stool softener to prevent straining. Patient education -Eat variety of fruit and veggies, limit amount of fat & reduce salt intake. -Stop smoking -Do simple, regular exercise 20-30 mins a day -Explain the medication -Reduce anxiety by deep breathing. -Avoid sex for a few weeks. Consult the doctor. Cardiac rehabilitation Phase I (admission till discharge)-inapatient Self care, exercise, diet, smoking Phase II (After discharge and last for 4-8 weeks) Level of activity, psychological, modify risk factors, and return to work. Phase III (Maintenance)- Follow-up. CORONARY ARTERY DISEASE (CAD)
Definition: Hardening of the coronary arteries, this may cause angina pectoris and lead to myocardial infarction.
Clinical manifestation Chest pain/discomfort at arms, jaw, neck Shortness of breath Lightheaded Sweating Nausea and vomiting
Risk Factors Middle to old age Male Family history Hyperlipidemia Obesity Hypertension Smoking Diabetes Chronic Kidney disease Post-menopause
Types of angina Stable Angina Unstable Angina Cause by the same precipitating factors each time (eg: exercise) Pain reduce by rest and taking S/L GTN
Due to 75 blockage of coronary artery.
Cause by change in pattern of stable angina
Pain need more than rest & GTN. A medical emergency Due to plague instability & can cause MI
Management: g Accurate assessment of chest pain to differentiate unstable & stable angina. g Recognize myocardial ischemia by intensity of pain, vital signs, 12-lead ECG, and immediate fibrinolytic & heparin administered or PCI are performed to detect obstruction. g Relieve chest pain by giving oxygen, nitroglycerin, analgesics, and aspirin. g Maintain calm environment to reduce anxiety g Patient education: -Alert nurse for any chest pain or discomfort -Avoid straining -Risk factor modification -Identify signs & symptoms of angina -Importance of medication -When to call doctors/seek treatment -Emotion & stress management
HEART FAILURE
Definition: A condition in which the heart cannot pump blood at a volume required to meet the bodys needs.
Classification (based on symptoms & pts effort) Class I Normal daily activity does not initiate symptoms. Class II Normal daily activity initiate symptoms, bit subside with rest. Class III Minimal activity initiate symptoms. No symptoms at rest. Class IV Any activity initiates symptoms and also present at rest. Types of Heart Failure
Management: Medical Pulmonary Artery Catheter (PAC) to monitor left ventricle function Administer diuretics & fluid restriction to prevent fluid overload. Serve Morphine to reduce anxiety & facilitate peripheral dilatation Serve vasodilator (nitroglycerin) to reduce preload & dilate coronary arteries. Intra-aortic Balloon Pump (IABP) to support inadequate CO and blood pressure. Administer inotropic (dopamine) to increase contractility. Administer ACEi to inhibit ventricular remodelling slows ventricular dilation. Administer Beta blocker (carvedilol) to reduce heart rate Serve Digoxin to control Atrial Fibrillation Permanent pacemaker
Nursing Optimizing cardiopulmonary function -Assess ECG for dysrhythmia due to Digoxin toxicity and electrolyte imbalance. -Assess respiration pattern & rate for pulmonary congestion -Give oxygen if dyspnea -Administer diuretic or vasodilator to reduce preload and afterload -Serve Morphine to decrease anxiety -Assist in intubation & mechanical Ventilation -Daily weight in fluid management.
Left Ventricular Failure (LVF) Disturbance of contractility of left ventricle Results in low CO, increase afterload & vascular resistance, and pulmonary edema Symptoms: Tachypnea, tachycardia, cough Right Ventricular Failure (RVF) Disturbance of contractility of right ventricle Due to acute condition like pulmonary embolus and right ventricle infarction. Symptoms: Peripheral edema, high CVP, weakness, jugular venous distention Systolic Heart Failure Abnormality of heart muscle that decrease contractility during systolic & reduse quantity of blood that can be pumped out. Symptoms: Dysnea, fluid overload, exercise intolerance. Diastolic Heart Failure Abnormality in heart muscle making it unable to rest, stretch or fill during diastolic. Ejection fraction may be normal or low. Congestive Heart Failure Determined by rapidity of syndrome develops, presents of compensatory mechanism & presence of fluid accumulation. In acute, it is sudden onset with no compensatory mechanism. In chronic HF, symptoms may be tolerable with medication, diet & activity level. Promote comfort and emotional support -Restrict activity and assist ADL during SOB -Put patient on bed rest -Prop up the bed for maximal lung expansion -Document signs of activity intolerance such as dysnea, fatigue & tachycardia. Monitor effects of pharmacological therapy -Know the action, side effect & toxic level -Monitor hemodynamic status closely -Document correctly intake & output Provide adequate nutritional intake -Monitor closely for nausea & low appetite -Encourage small, frequent meal -Advice family members to provide tasty food from home which compatible with condition. Provide patient education -Assess understanding of the disease & risk factors of heart failure. -Educate the importance of diet restriction -Educate importance of daily weight, fluid restriction & medication to control symptom -Educate importance of lifestyle changes like smoking, weight loss & exercise -Inform when to call or seek treatment
VALVULAR HEART DISEASE
Definition: Several disorders and diseases of the heart valves, which are the tissue flaps that regulate the flow of blood through the chambers of the heart.
Mitral Valve Stenosis
Definition: Narrowing of mitral valve orifice (<2cm 2 ). The thickened, calcified valve cannot open or close passively, obstructing flow of blood from left atrium to left ventricle.
Diagnostic test: I. Chest X-ray: Pulmonary congestion, enlargement of main arteries & Lt atrium. II. ECG: Atrial fibrillation III. ECHO: Valve leaflet thickening & restricted opening IV. Cardiac catheterization
Treatment: Diuretics & sodium restriction Anti-arrhythmia to treat atrial fibrillation Anticoagulant to prevent thromboembolism Beta blockers/CCB/digoxin to control HR Antibiotic for prophylaxis of rheumatic fever Percutaneous Balloon Vulvotomy Mitral commissurotomy Mitral valve replacement
Mitral Valve Regurgitation
Definition: Backflow of blood in left atrium with each ventricular contraction due to rupture of chordae tendinae/ papillary muscle (emergency) or dilatation of left atrium to maintain CO. Clinical Manifestation: Dyspnea Fatigue Palpitation Orthopnea Paroxysmal nocturnal dyspnea Pulmonary venous hypertension
Diagnostic test: I. Chest X-ray: Left atrial enlargement and cardiomegaly II. ECHO
Treatment Acute Chronic IV Nitropruside to reduce afterload IV Nitroglycerin to reduce pulmonary pressures IABP to stabilize vital signs Mitral valve repair/ replacement Medication to delay surgery or preventing left ventricular dysfunction Assess ventricular size, function & severity every 6-12 month by ECHO.
Aortic Valve Stenosis
Definition: Narrowing of aortic valve orifice which impedes the blood flow from heart to body.
Diagnostic test: I. ECG: Abnormal pattern reflecting thickening of heart muscle II. Chest X-ray: Dilation of aorta above the valve III. ECHO: Diagnose & evaluate the severity
Treatment: - Restriction from activity - 6-12 month evaluation by ECHO to indicate aortic valve replacement. - Antibiotic prophylaxis given to avoid endocarditis. - Diuretics
Aortic Valve Regurgitation
Definition: Backflow of blood into the left ventricle during ventricular diastole.
Treatment: Aortic valve replacement
Tricuspid Valve Stenosis
Definition: Narrowing of the tricuspid valve orifice results in increase pressure in right ventricle.
Diagnostic test: I. ECG: Tall P wave in sinus rhythm II. ECHO: To identify the presence & severity.
Definition: Stenosis- Narrowing of the pulmonic valve orifice Regurgitation- Backflow of blood from pulmonary artery into the right ventricle
Diagnostic test: I. ECG: Incomplete right BBB II. Chest X-ray: Prominent pulmonary artery III. ECHO: Identify right ventricular hypertrophy IV. Catheterization: Comfirm the diagnosis
CARDIOMYOPATHY
Definition: A disease of heart muscle & associated with ventricular dysfunction.
Hypertropic Obstructive Cardiomyopathy
Definition: Excessive myocardial hypertrophy which the heart able to contract but unable to relax and remain stiff in diastole.
Treatment: Beta blockers to reduce heart rate Anti-arrhythmia Anti-coagulant Activity restriction to reduce sudden death Implantable cardioverter defibrillator Myectomy to improve blood flow from heart.
Dilated Cardiomyopathy
Definition: Characterized as dilation of both ventricles without muscle hypertrophy.
Treatment: Restoring blood volume and ensure oxygenation and blood pressure adequate. -Normal Saline -Hartmann Solution Crystalloids -Dextrose solution -Albumin -Polygeline -Gelatin -Hetastarch -Blood products Airway managed & initiate oxygen therapy Vasopressant to induce vasoconstriction Use anti-shock trousers to concentrate blood in vital organs (lungs, brain, heart) Keep patient warm Antibiotics to prevent sepsis Adrenaline to stimulate cardiac performance Corticosteroid to reduce inflammation Trendelenburg position to shunt blood back to bodys core Chest tube to treat pneumo/hemothorax Thrombolysis to reduce size of clot. Pericardiocentesis to treat tamponade
CARDIAC TAMPONADE
Definition: Sudden accumulation of blood, fluid, clots, pus or gas in pericardial space resulting in compression of heart muscle & interfere systole & diastole.
Management: Pericardiocentesis -Aspirate fluid from pericardial by needle Subxiphoid pericardiostomy -Drain pericardial sac Emergency thoracotomy -Pericardial sac evacuation Fluid resuscitation -Blood products, colloids, crystalloids Inotropic agent -Increase myocardial contractility and CO Airway -Oxygen, intubation, mechanical ventilation ELECTROCARDIOGRAM (ECG)
12 lead ECG consist of: a) 6 limb leads (I, II, III, aVR, aVL, aVF) b) 6 chest leads (V1-V6) c) Standard speed of 25mm/second d) Small box = 0.04 sec = 1 mm e) Large box = 0.20 sec = 5 mm
P wave Atrial contraction 0.08-0.10 sec QRS complex Ventricular contraction 0.06-0.10 sec T wave Ventricular relax - PR interval AV node function 0.12-0.20 sec
ST segment + Measured from end of QRS complex to beginning of T wave. + Evaluate base on shape & location + Normally flat/isoelectric level
1 mm above Myocardial ischemia 2 mm above Myocardial infarction/ pericarditis 1 mm below Myocardial ischemia
QT interval + Indicates total time from onset of contraction to relaxation. + Shorten with fast HR, lengthen in slow HR + Normal: <46 sec (women), <0.45 sec (male) + Prolong indicates torsades de pointes, electrolyte imbalance, dysrhythmic treatment
Reading ECG 1. P wave presence and have relation with QRS. 2. PR interval duration 3. QRS complex shape, width & duration 4. QT segment length 5. ST segment elevation.
Methods in calculating heart rate i. No. of R-R intervals in 6 sec times 10 (Irregular rhythm) ii. No. of large boxes between QRS complex divided into 300 iii. No. of small boxes between QRS complex divided into 1500
*If HR>200 bpm or <30 bpm, emergency measures are taken. Initial Hyperperfusion causes hypoxia. Cellsperform anaerobic respiration leading to lactate & pyruvate build up causing metabolic acidosis. Compensatory Hyerventilate to clear CO 2 and improve pH. Baroreceptors detect hypotension due to vasodilatation Adrenaline is released to increase BP. Renin-angitensin axis is activated and vasopresssin released to conserve fluid via kidneys reducing urine output. Vessels in other organ also constrict to divert blood to heart, lungs & kidneys. Progressive (decompensating) Vessel constriction causes blood remain in capillaries. Hydrostatic pressure increase and histamine released cause leakage of fluid and protein into surrounding tissue. Blood concentration increase causing sludging of microcirculation. Vital organ compromised due to reduced perfusion. Refractory Vital organ failed and brain death occured. Death will occur imminently. Colloids HEMODYNAMIC MONITORING
Definition: Is the bedside measurement of the ever-changing pressure of blood flow through the cardiac, pulmonary & systemic vasculature via invasive catheters.
Benefits: Improve patient outcome Lower mortality rates Better quality of life after critical illness
Measurement: Direct Indirect (calculation) CVP Rt Ventricle Pressure Pulmonary Artery P. Cardiac output Cardiac Index Lt Ventricular Ejection Fraction Lt Atrial Pressure Capillary Wedge P.
Tools: Intra-Arterial Catheters (IAC) Purpose Measure MAP correctly Draw blood for ABG Monitor Arterial BP
Insertion site * Radial artery * Femoral artery * Dorsalis pedis * Brachial artery * Axillary artery Central Venous Access
Insertion site * Subclavian vein * Brachial vein Jugular vein Purpose When peripheral site nor accessible For fluid resuscitation CVP monitoring Access for PAC Monitor blood circulation Pulmonary Artery Catheter (PAC)
Weaning: O Hemodynamic stable O No chest pain O Adequate urine output ACUTE LUNG INJURY (ALI)
Definition: A systemic process of pulmonary manifestation which cause multiple organ dysfunction syndromes. Severe ALI is known as Acute Respiratory Distress Syndrome (ARDS).
Clinical Manifestation: Exudative phase Fibroproliferative phase * Tachypnea * Restlessness * Anxiety * Use accessory muscles * Agitation * Dyspnea * Fatigue * Use accessory muscle excessively * Fine crackles
Diagnostic test a. Chest X-ray b. Sputum culture c. Bronchoscopy d. Full Blood Count e. Arterial Blood Gases
Nursing management: i. Optimize oxygenation & ventilation -Oxygen therapy -Positioning -Secretion clearance -Bronchodilators ii. Prevent infection spreading -Proper hand washing -Administer antibiotic iii. Provide comfort & emotional support -Adequate rest -Perform procedures as needed -Explanation on procedures iv. Prevent complications -Close monitoring -Aseptic technique
PULMONARY EMBOLISM
Definition: Occurs when thrombotic embolus (clots) or non- embolus (fat, air, foreign bodies) stuck into the pulmonary arterial system, disrupting blood flow to the lungs.
Pathophysiology
After direct/ indirect injury, inflammatory- immune system is stimulated Inflammatory mediators released from the site Causes neutrophils, macrophages & platelet accumulate in pulmonary artery. Initiate humoral mediators that damage alveolar-capillary mambrane. Alveolar collapse and cause increase work of breathing Hypoxemia When occluded, alveolar dead space work of breathing Hypercapnia & hypoxia causes bronchoconstriction pulmonary vascular resistance right ventricular workload Clinical manifestation: Tachycardia Hemoptysis Tachypnea Cough Dyspnea Crackles Anxiety Fever
Risk factors: Venous stasis (AF, CO, immobility) Injury to vessels (infection, incision) Polycythemia Cardivascular disease (HF, cardiomyopathy) Cancer Trauma Pregnancy
Oxygen administration: Types Amount/percentage Nasal cannula 2-6 Lpm/25-50% Face mask 6-10 Lpm/ 35-60% Partial rebreather >10 Lpm/ >60% Non rebreather >10Lpm/ 60-95% Demand valve 100 Lpm/ 100% Venturi mask (15 Lpm) With reservoir 50% No reservoir >95%
Intubation Techniques Head tilt, chin lift: Tongue may obstruct Jaw thrust: For spinal injury patient Body position Lateral position allow fluid drain out Used when no spinal injury If so, patient secured on a board first. Airway adjunct Oropharyngeal: -For unconscious patient -Measure from mouth to angle of mandible Nasopharygeal: -For conscious patient -When oropharungeal airway not accessible -Measure from tip of nose to end of earlobe Laryngeal mask: -For unconscious patient -Not suitable if esophagus is injured -Must be remove after patient conscious -Does not prevent aspiration Tracheostomy: -For prolong ventilation -When patient fail to be intubated -Done in OT
Complications of intubation: Laceration of gum, lip, vocal cord, pharynx Broken teeth Vocal cord paralysis Pneumothorax Esophageal intubation ETT dislodgement
Suctioning: O Hyperventilate patient or apply high- concentration of oxygen before suction O Use sterile apparatus O Maximum of 10 sec on each suction O Be gentle O Rotate the catheter when withdrawing it. O Apply aseptic technique O Use soft, flexible catheters O Monitor for arrhythmia O Attach oxygen after suction
MECHANICAL VENTILATION
Definition: A mode of assisted or controlled ventilation using mechanical devices that cycle automatically to generate airway pressure.
Types: i. Volume-cycled: Preset tidal volume ii. Pressure-cycled: Preset pressure limit iii. Flow-cycled: Preset flow rate iv. Time-cycled: Preset time factor
Modes:
Spontaneous A closed pneumothorax (no leak) Causes: Rupture of visceral layer due to infection (primary), disease complication (secondary) Symptoms happen during rest Traumatic Can be opened (opening in chest wall) or closed Causes: Penetrating injury (biopsy, thoracocentesis), fracture, PEEP, CPR Tension Air enter pleura space when inhale and cannot escape because of flap-valve effect. Life- threatening ( CO) Causes: Trauma, infection, mechanical ventilation Control Ventilation (CV) Deliver preset volume/pressure despite own inspiratory effort Used for apneic patient Assist-Control Ventilation (ACV) Deliver breath in response to own effort & when fail to breathe. Used in spontaneous breathing with weaken respiratory muscle Synchronize Intermitten Mandatory Ventilation (SIMV) Ventilator breath are synchronize with own effort Used in weaning from ventilation Pressure Support Ventilation (PSV) Preset pressure that augment own inspiratory effort & decrease work of breathing Used in weaning with SIMV mode Positive End Expiratory Pressure (PEEP) Used with CV, AC & SIMV to improve oxygenation by opening collapse alveoli. Constant Positive Airway Pressure (CPAP) Similar to PEEP but used only with spontaneously breathing patient. Maintain constant +ve pressure in airways. Independent Lung Ventilation (ILV) Ventilate each lung separately. Requires 2 ventilator and sedation. Used in unilateral lung disease/ different disease process in each lung High Frequency Ventilation (HFV) Deliver small gas amount at rapid rate (60- 100 bpm). Require sedation Used in hemodynamic instability, in short- term procedure or risk of pneumothorax. Inverse Ratio Ventilation (IRV) I:E ratio reversed to allow longer inspiration. Require sedation. Improve oxygenation in hypoxic patient with PEEP. Keeps alveoli from collapse. Settings: Ventilator Modes Modes used in delivering positive pressure. Respiratory Rate Number of breath ventilator delivers per minute (10-12/min) Tidal Volume Volume delivered to patient during normal ventilator breath (7-10 ml/kg). Volume >10 ml/kg cause volutrauma. Inspiratory flow A measure of preset respiratory volume: the more quantity of a flow, the more quickly ventilator will submit mandatory respiratory volume (45-60 L/min) I:E ratio Ratio comparing time delivering O2 and time to exhale (1:2). PEEP Positive pressure applied at end of expiration (3-5 cm H2O) FiO2 Select delivery of O2 (21- 100%). Should be the lowest level to prevent oxygen toxicity. Inspiratory trigger A control that adjust ventilator response to patient respiratory.
Criteria for starting mechanical ventilation: i. Respiratory rate >35 or <5 breaths/minute ii. Hypoxia: central cyanosis iii. Hypercapnia iv. Decreasing conscious level v. Significant chest trauma vi. Tidal volume <5ml/kg vii. Control ICP in head injury viii. Following cardiac arrest ix. Prolong major surgery
Definition of weaning: Gradual withdrawal of the mechanical ventilator & reestablishment of spontaneous breathing
Criteria for weaning: a. Respiratory rate <25 per min b. Tidal volume 3-5 ml/kg c. pH >7.35 d. PaO2 >80 mmHg with FiO2 <0.5 e. PaCO2 35-45 mmHg
Factors to consider before weaning -Resolution of underlying pathologic condition -Chest X-ray show good lung expansion -Acceptable ABG with ventilator support -Sepsis under control -Awake with intact respiratory drive -Minimal inotropic support -Good hydration with normal serum electrolyte -Adequate nutrition & energy -Intact gag & cough reflex before extubation
Complications: Mechanical- Equipment malfunction a) Ventilator Fail to cycle, Power failure b) Circuit Disconnection, Infection c) Humidifier Inadequate humidification, overheating Physiological A. Respiratory -Barotrauma -Atelectasis -Infection (VAP) B. Cardiovascular -Decrease venous return and CO C. Gastrointestinal -Gastric ulceration -Microaspiration D. Renal/ hepatic -Decrease urine output -Sodium & water retention -Decrease portal blood flow E. Central Nervous System -Decrease cerebral perfusion following excessive PEEP
Drugs used in managing ventilated patient: a) Sedative/ analgesics -Midazolam -Morphine -Propofol b) Neuromuscular Blocking Agent (NMBA) -Suxamethonium -Vecuronium -Atracurium
Care of Patient on Mechanical Ventilator Check ventilator settings according to doctors order every shift Make sure alarm are set Empty ventilator tubing when moisture collects. Never empty the fluid back into the cascade Ensure temperature of delivered air maintained at body temperature If on PEEP, observe peak airway pressure to determine the proper level Assess patients respiratory status every shift: Take vital signs 4 hourly Check cuff pressure everyday to ensure tidal volume Provide mouth care every 2-4 hours Observe the need for suction every 2 hours Provide tracheostomy care every shift. Change tube tape as needed Check mouth for pressure sores. Move the tube to opposite side of mouth every 24 hour to prevent ulcers Maintain accurate intake & output records Position patient every 2 hours to prevent complication of immobility Plan nursing care to provide rest Include patient & family members in care Provide materials for communication Observe for gastrointestinal distress Administer medication as appropriate Initiate relaxation technique Monitor for complication (barotraumas, CO) Monitor readiness to wean. NON INVASIVE VENTILATION
Definition: Delivery of mechanical ventilation with a nasal or face mask.
Advantages: O Prevent intubation O Enhance alveolar ventilation O work of breathing O Improve gaseous exchange O nosocomial infection O Enhance patient comfort O length of stay O cost
Indication g AECOPD & respiratory failure g Respiratory failure with hypercapnia g Respiratory failure with acute hypoxemia g Asthma
Methods: 1. Continuous Positive Airway Pressure (CPAP) o Air delivered via mask fit to patients face o Pump provide positive pressure o Increase amount of air breathed in o Not increase work of breathing o Patient breathe spontaneously o Usual range 5-15 cmH20 2. Bilevel Positive Airway Pressure (BiPAP) o Provide higher positive pressure for inspiration o Enhance oxygenation & ventilation o Higher pressure is for inhalation (IPAP), lower pressure for expiration (EPAP) o When inhale, air flow in high pressure to support inhalation. o Increase delivery of air with less breathing workload.
Nursing management Claustrophobia Assess for comfort Serve anxiolytic Pressure on face Place hydrocolloid dressing Mucosal dryness Apply lip balm or nasal spray Stomach distension Insert nasogastric tube Aspiration Check for nausea, abdo girth Serve antiemetic Corneal irritation Ensure mask fit well Apply eye drop Hypoventilate Ensure mask fit well
Definition: Tissue damage caused by such agents as heat, chemicals, electricity, UV light or nuclear radiation. Leading cause of death is infection.
Types Causes Thermal Hot water, flammable liquid, explosion, fire Electrical Massive electrical current Chemical Strong acid/ alkali, mustard gas Radiation Exposure to UV light
Classification of burn Major 25% of TBSA 10% of TBSA full-thickness burn Deep burn (head, perineum) Inhalational injury Chemical/high voltage burn Moderate 15-25% of TBSA Superficial partial thickness burn (head, perineum, limbs) Suspected child abuse Concomitant trauma Minor 15% of TBSA Estimation of burn size I. Rule of nine Divides body part into 9% of TBSA each II. Lund & Browder chart Surface area is based on age III. Palmar method Use patient own hand, representing 11% of TBSA
Degree of burns 1 st degree -Superficial burn -Causes pain, redness, swelling -Heal within 3-5 days 2 nd degree -Partial thickness burn -Causes pain, swelling, blister -Heal within 10-14 days 3 rd degree -Full thickness burn -Causes black,char skin, numb -Heal within 30 days-months
Management: a) Resuscitative phase -Adult (> 15%), children (>10%) -Fluid resuscitation (Ringers Lactate): Parklands Formula (4 x BSA involved x body weight) -50% given in 1 st 8 hours, 50% nest 16 hours b) Acute phase -Wound care -Open dressing: Apply topical agent with gauze -Close dressing: Use gauze to cover after apply topical agents -Apply topical antimicrobial (Silver nitrate) c) Rehabilitation phase -Physiotherapy -Psychiatry -Social worker
Definition: A metabolic state resulting from a profound lack of insulin, usually found in type I DM. Inability to inhibit glucose production from the liver results in hyperglycemia, which can be extreme and lead to severe dehydration.
Pathophysiology
Clinical Manifestations: Hyperglycemia Coma ketone level Shortness of breath Polydipsia Weakness Polyuria Weight loss Polyphagia Abdominal pain Nausea & vomiting Dehydration
Complication: 1) Cerebral edema -Brain swell due to water accumulation 2) Acute kidney failure -Caused by severe dehydration 3) Acute Respiratory Distress Syndrome -Lungs filled with fluid causing SOB 4) Hypoglycemia -Insulin enter into cells and glucose level 5) Hypokalemia -Due to fluid & insulin used in treating DKA
Definition: Hyperosmolarity & severe hyperglycemia predominate with change of mental status due to insulin resistance. Occurs in type II DM.
Pathophysiology
Hyperglycemia (absolute deficit in insulin) Inability of glucose to move into cells, increasing its level Fat from adipose tissue converted into free fatty acids (FFA) FFA converted to glucose by liver Liver also convert glycogen into glucose Worsen the hyperglycemia Deficit in insulin prevent glucose enter cells Glucose level & blood become hyperosmolar Fluid drawn from the cell into vascular bed Body try to eliminate excessive glucose by urinating If patient do not consume enough water, it may results in severe dehydration Clinical manifestations: Hyperglycemia Polyuria Dehydration Weakness Excessive thirst Weight loss Confusion Fatigue
Risk factors: A. Poor DM control B. Non compliant to DM treatment C. Drink inadequate water D. Intravenous feeding- glucose E. Peritoneal dialysis F. Diuretics
Complication: 1) Shock 2) Coma 3) Acute tubular necrosis 4) Vascular thrombosis 5) Death
Management for DKA and HHNS: Medical Nursing * Fluid resuscitation * Administer insulin * Restore electrolyte * Patent airway * Enough ventilation & oxygenation * Close monitoring * Administer fluid, insulin, electrolyte * Monitor compliant to therapy * Prevent complications * Patient education
Patient education for DKA & HHNS: a. Control blood sugar b. Consult doctor for blood sugar level target c. Drink a lot of water d. Take medication as ordered e. Watch for signs & symptoms- Ketone in urine
Comparison between DKA & HHNS DKA HHNS In type I DM In type II DM Sudden onset Slow onset ketone level Normal level Serum sodium low Serum sodium high Low bicarb level Normal level Urine ketone present No urine ketone
POLYTRAUMA
Definition: Consecutive systemic reactions which may lead to dysfunction or failure of remote organs and vital systems.
Trauma death: Second death peak occurs within minutes to several hours after injury. This period is called Golden Hour characterized by: -Rapid transportation -Rapid assessment& stabilization -Rapid definitive care
Conditions & its management: Head injury * Airway, breathing, circulation * Neurological assessment; GCS Obtain CT brain if comatose, unequal pupils, GCS <13/15
Triaging O Categorising the patient according to treatment priority. O A 24 hour basis by well trained Triage Officers. O Triage criteria: Non-critical Walk-in & stable Semi-critical Hemodynamically stable but unable to walk Critical Critically ill, require immediate treatment.
Zone & facilities: Resuscitation zone Resuscitation bays -Emergency treatment golden hour -Activation of trauma team Critical care bays -Observation & monitoring Immediate Care zone Immediate bays -Active bays for incoming semicritical Observation bays -Observation for semi- critical cases -Duration stay <12 hours Green zone Consultation room -Minor treatment prior to be discharge -Eg: injection, dressing Asthma bay No waiting time Emergency treatment One Stop Crisis Centre (OSCC) Victims of domestic violence, rape, child abuse Registration done in the room by emergency staff
Stabilization & transport of critically ill patient: Indication Contraindication Diagnostic purpose Therapeutic purpose (surgery) Specialized care (ED to ICU) Increase potential risk Unstable/potential patient
Potential mishap: Accidental extubation Ventilator disconnect ECG disconnect Monitor power failure Vaso-active drug interruption IV infiltration or disconnection
Elements: i. Communication - Reason for transport -Patients condition -Equipment needed -Notify receiving department before transfer
ii. Equipments -Small size, light -Compatible -Safe to staff and patient Monitors -Know how to operate -Monitors ECG, ABP, ICP, SpO2, capnograph Ventilators -Different modes -High & low pressure alarms -Electrically powered -Have humidification system -Oxygen supply, backup Medication & infusion -List of drugs to be used -Aware of drug effects -Use plastic infusion bag -Test IV drip before infuse iii. Monitoring -Pulse, SpO2, BP, RR iv. Handling over (documentation) -Indication for transport -Patient status during transport (Vital signs, level of consciousness)
COMMON DRUGS IN ICU
Sedation Indication Relieve pain Reduce anxiety & agitation Provide amnesia Reduce patient-ventilator dysynchrony Reduce respiratory muscle oxygen consumption Common drugs BDZ * Diazepam * Lorazepam * Midazolam + No analgesic properties + Lipid soluble + Interact with propranolol Propofol + Respiratory & CVS depression + Only in ventilated patient Butyrophenones * Haloperidol + Anti-psychotic tranquilizer + In agitated, delirious &psychotic patient + Patient can develop EPS
+ Positive inotrope & vasodilator + Little effect in HR + Used in CHF + Risk of tachyarrhythmia Adrenaline + Very potent agent + Effect on metabolic rate + Useful in anaphylaxis + Risk of coronary ischemia, renal vasoconstriction Noradrenaline + Potent agent + Tend to spare brain & heart + Good in increasing SVR + Can cause reflex bradycardia Phenylephrine + Pure agent + Cause minimal increase in HR or contractility + Does not spare brain & heart Ephedrine + Release tissue stores of adrenaline + Last longer & less potent than adrenaline Vasopressin + Useful in septic shock + To parallel HRT Nitroglycerine + Venodilator at low dose + Arteriodilation at high dose + Short duration, rapid onset + Risk of ICP, headache Nitroprusside + Balanced vasodilator + Rapid onset + Used in HPT emergency, severe CHF, aortic dissection + Risk of CN poisoning, ICP Labetolol + 1 & blocker + Does not ICP + Used in HPT emergency, aortic dissection