Download Critical Care Nursing Fourth Class

Critical Care Nursing
Fourth Class/ Nursing College
Dr.Huda B.Hassan
Critical Care Nursing (1)
Nurse as Patient Advocate
Evolution of Critical Care
•
Beginnings with polio units, recovery room, and coronary care units
•
Patient outcomes improved
Critical Care in 21st Century
Professional Organizations
American Association of Critical-Care Nurses (AACN)
–
AACN’s Vision
Create a healthcare system driven by patient’s and family’s needs in which critical care
nurses make their optimum contributions
Critical Care Certification
Standards of Practice (Medina, 2000)
Trends and Issues
•
SBAR communication strategy
The Critical Care Experience (2)
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Critically ill patients at high risk for actual or potential life-threatening health
problems
•
Critically ill patients cared for in a variety of settings, not just the critical care unit
Critical Care Environment
Healthy Work Environment
What strategies can be used to enhance communication?
Communication Strategies
•
Critically Ill Patient responses vary according to:
Patients’ Recall About Critical Care:
Psychosocial Support
What are strategies to achieve these goals?
Perceptions of Caring Practices: Critical care patients need to feel safe
• Nursing interventions:
Quality of Life After Critical Care
•
from the unit
Geriatric Concerns:
•
•
Diminished ability to adapt or cope to stressors of critical illness
At greater risk for negative outcomes
Family Members:
Calgary Family Assessment
Family Needs
Family Interventions
Comfort and Sedation (3)
• Pain occurs from a variety of causes
•
•
Pain
– Unpleasant sensory and emotional experience associated with actual or
potential tissue damage
– It is what the patient says it is
Anxiety
• Influences anxiety
Physiology
Positive Effects of Pain/Anxiety
•
•
•
Increase performance levels
Removes one from potential harm
Fight-or-flight response
Negative Effects of Pain/Anxiety:
5-Step Assessment of Pain
Subjective Assessment Tools
Subjective PQRST: Chest pain characteristics
•
P
=
The Face, Legs, Activity, Cry, Consolability scale or FLACC scale is a measurement used
to assess pain for children between the ages of 2 months and 7 years or individuals that are
unable to communicate their pain. The scale is scored in a range of 0–10 with 0 representing
no pain. The scale has five criteria, which are each assigned a score of 0, 1 or 2.
•
•
Sedation Assessment—Tools
Sedation medication is given to reduce symptoms; dose is adjusted based on tools or
scales
– Richmond Agitation-Sedation Scale (RASS)
– Ramsey Sedation Scale (Ramsey)
– Sedation-Agitation Scale (SAS)
Interobserver agreement in assessment using various scales is important
Score
+4
+3
+2
+1
0
-1
Term
Combative
Very agitated
Agitated
Restless
Alert and calm
Drowsy
-2
Light sedation
-3
-4
Moderate sedation
Deep sedation
-5
Unarousable
Richmond Agitation Sedation Scale (RASS) *
Description
Overtly combative, violent, immediate danger to staff
Pulls or removes tube(s) or catheter(s); aggressive
Frequent non-purposeful movement, fights ventilator
Anxious but movements not aggressive vigorous
Not fully alert, but has sustained awakening (eyeopening/eye contact) to voice (>10 seconds)
Briefly awakens with eye contact to voice (<10 seconds)
Movement or eye opening to voice (but no eye contact)
No response to voice, but movement or eye opening to
physical stimulation
No response to voice or physical stimulation
Verbal Stimulation
Verbal Stimulation
Verbal Stimulation
Physical Stimulation
Physical Stimulation
Sedation Assessment—Technology
–
Delirium
•
•
Acutely changing mental status
• Indications
Nursing Care for Neuromuscular Blockad:
Preventing Pain is More Effective Than Treating Pain”
Management Challenges
Nutritional Support(4)
•
•
All critically ill patients are assumed to be at nutritional risk
Nutritional support is an important part of overall care plan
Anatomy and Physiology Review
Nutritional Assessment:
• Objective data in ICU patient
• Subjective data in ICU patient
Nutritional Therapy Goal:
Nutrition Care Plan:
• Delivery of nutrients to GI tract
Enteral Formulas
Guidelines for Enteral Feeding:
Drug-Nutrient Interactions:
• Check medications for compatibility with enteral feeding
Nursing Care:
•
Monitoring Complications:
Prevent Complications:
Monitoring and Evaluating:
Dysrhythmia Interpretation and Management(5, 6)
• Dysrhythmia interpretation is a fundamental skill of critical care nurses
• Crucial for early nursing and medical intervention
Basic Electrophysiology:
Cardiac Cycle:
Cardiac Action Potential:
Muscular Contraction:
• Depolarization leads to contraction
• Repolarization leads to resting and filling of ventricles from atria
• ECG is evidence of electrical activity, not contraction
Cardiac Conduction Pathway:
• SA node
12-Lead ECG:
• Leads

None of the 12 leads record activity over the posterior of the heart
Cardiac Monitoring:
Analyzing Cardiac Rhythms:
• Graph paper
– Used to standardize tracings
– Vertical boxes measure voltage/amplitude
– Horizontal boxes measure time
Measuring:
Rate:
•
Waveform Configuration and Location
Interval
•
Rhythm Interpretation:
Basic Dysrhythmias:
–
Normal Sinus Rhythm:
Normal Sinus Rhythm
•
Sinus Tachycardia:
Assess for symptoms of low cardiac output
Sinus Tachycardia
Sinus Bradycardia:
Sinus Bradycardia
Sinus Dysrhythmia:
Sinus Dysrhythmia
Sinus Arrest or Exit Block:
•
Sinus Arrest or Exit Block:
Atrial Dysrhythmias:


Causes
Premature Atrial Contractions:
Premature Atrial Contractions
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Ventilators Assistance (7,8)
Essential nursing interventions
Respiratory Anatomy and Physiology:
Physiology of Breathing:
Gas Exchange:
Regulation of Breathing:
Terminology:
Work of Breathing (WOB):
Compliance:
Resistance:
Lung Volumes and Capacities:
•
•
Assess baseline function
Monitor responses
Volumes and Capacities
Selected Measures:
Assessment:
Health History:
Physical Examination:
Palpation:
Percussion:
•
Auscultation:
• Assess breath sounds, presence of adventitious lung sounds, voice sounds
Oxygenation:
– )
Terms:
• Hypoxemia: decreased oxygenation of arterial blood
• Hypoxia: decreased oxygenation at tissue level
• PaO2 and SaO2 Relationship:
pH:
• Concentration of hydrogen ions (H+)
PaCO2:
HCO3—Bicarbonate:
–
Buffer System:
Bicarbonate Buffer System
Respiratory Buffer System
Buffer Systems
Interpretation of ABGs:
Oxygenation:
•
Pulse oximetry (SpO2)
Assessment of Ventilation
Oxygen Administration:
Oxygen Delivery Devices:
Airway Management:
:
Endotracheal Tube
Insertion of an endotracheal tube through the mouth or nose
– Which is preferred and why?
• Used to:
Verify Placement:
•
Nasotracheal Intubation:
Tracheostomy:
Tracheostomy:
•
Endotracheal Suctioning:
Indicators for Ventilation:
Positive Pressure Ventilation:
• Movement of gases into lungs through positive pressure
• Opposite of normal respirations
Ventilator Settings:
Shock, Sepsis(9,10)
•
Shock is a clinical syndrome
•
Normal Anatomy and Physiology:
Pathophysiology:
Stages of Shock—
Stage I: Initiation
• Hypoperfusion: inadequate delivery or extraction of oxygen
• No obvious clinical signs
• Early, reversible
Stage II: Compensatory:
• Sustained reduction in tissue perfusion
• Initiation of compensatory mechanisms
– Neural: baroreceptors and chemoreceptors
– Endocrine: ACTH and ADH
– Chemical
• Low oxygen tension
• Hyperventilation and respiratory alkalosis
Stage III: Progressive:
• Failure compensatory mechanisms
•
Profound CV cardiovascular effects
– Increased hypoperfusion
– Vasoconstriction
• Extremity ischemia
• Cellular hypoxia
• Lactic acid production
• Failure Na+/K+ pump
• Increased capillary hydrostatic pressure
• Intravascular fluid shifts
– Interstitial edema
– Decreased circulating intravascular volume
• Decreased coronary perfusion
– MDF released
– Decreased myocardial contractility
Stage IV: Refractory:
• Prolonged inadequate tissue perfusion
– Unresponsive to therapy
– Contributes to multiple organ dysfunction and death
Systemic Inflammatory Response Syndrome (SIRS):
Shock Assessment:
• Central nervous system
• Cardiovascular system
• Pulmonary system
• Renal system
• Gastrointestinal (GI) system
– Slowing intestinal activity
• Decreased bowel sounds, distention, nausea, and constipation
• Hepatic
• Hematologic
• Integumentary
Laboratory Values:
Management:
Management:
– Administer supplemental oxygen
– Life-sustaining therapies/end of life
Mechanical Management:
Specific Classifications of Shock and Management—
Hypovolemic Shock:
Cardiogenic Shock:
• Arterial vasodilators
Obstructive Shock:
– Relief of compression or obstruction
—Distributive Shock:
Distributive Shock—Anaphylactic:
• Management
•
Distributive Shock—Septic