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Critical Care Nursing
4TH Class 2013-2014
General concepts in caring for critically ill
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Nutritional support.
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Mechanical ventilation.
•
Homodynamic monitoring.
•
Sedating and paralytic agents.
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Alteration in consciousness.
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Pain.
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Prolonged immobility.
-Definition of critical illness:Critical illness is any disease process which causes physiological instability leading to disability or
death within minutes or hours.
Perturbation of the neurological and cardio respiratory systems generally has the most immediate
life-threatening effects.
-Bedside examination for cardinal features of critical illness. HR = heart rate; RR = respiratory
rate; SBP = systolic blood pressure; UO = urinary output.
1-Nutritional support:- In the critically ill patient, malnutrition results in impaired immunologic
function, impaired ventilatory drive, and weaked respiratory muscles leading to prolonged
ventilator dependence and increased infectious morbidity and mortality rates.
Critical Care Nursing
4TH Class 2013-2014
General concepts in caring for critically ill
Critically ill patients are often unable to eat because of:1-Endotracheal intubation.
2-The need for mechanical ventilation.
3-Altered level of consciousness as a result of severe trauma, major surgery or acute medical
condition.
The benefits of nutrition support in the critically ill:•
Improved wound healing, a decreased catabolic response to injury.
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Improved gastrointestinal structure and function.
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Improved clinical outcomes including a reduction in complication rates and length of
stay with accompanying cost savings.
Using the guidelines:•
Step 1 ASSESSMENT Does the patient require nutritional support?
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Step 2 ADMINISTRATION which route(s) should be used?
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Step 3 ACHIEVEMENT (REVIEW) Are nutrition goals being met?
Step 1 Nutritional Risk Screening
Does this patient require nutritional support?
* Assessment Nutritional Statues
Impaired nutritional status
Severity of disease
(increase in requirements)
Score 0
Normal nutritional status
Normal nutritional requirements
Score 1
Wt loss >5% in 3 months or food
intake below 50-75% of normal
requirements in preceding week.
Hip fracture. Chronic patients in
(particular acute complications of
cirrhosis, COPD. Chronic diabetes
haemodialysis, oncology.
Wt loss >5% in 2 months or BMI
18.5-20.5 + impaired general
condition or food intake 25-60% of
normal requirement in preceding
week.
Major abdominal surgery, stroke
severe pneumonia, hematologic
malignancy.
(Mild)
Score 2
(Moderate)
,
Score 3
(Severe)
Wt loss >15% in 3 months or BMI
<18.5 + impaired general condition
or food intake 0-25% of normal
requirement in preceding week
Head injury, Bone marrow
transplant
Critical Care Nursing
4TH Class 2013-2014
General concepts in caring for critically ill
TOTAL SCORE:•
age adjustment (if patient ≥70 yrs add 1 to total score)
•
Score interpretation:- score ≥3 the patient is nutritionally at risk and a nutritional plan
should be initiated, score< 3
weekly re-screening of the patient. if the patient is
scheduled for a major operation a preventative nutrition plan should be considered to avoid
associated risk status.
Step 2 Administration route(s):•
Enteral Nutrition. nutritional support via placement through the nose, esophagus,
stomach, or intestines (duodenum or jejunum)
•
Parenteral Nutrition. Is feeding a person intravenously, bypassing the usual process
of eating and digestion. the person receives nutritional formulae that contain nutrients such
as glucose, amino acids, lipids and added vitamins and dietary minerals
Conditions That Require Other Nutrition Support during critical ill:•
Enteral
—Impaired ingestion.
—Inability to consume adequate nutrition orally.
—Impaired digestion, absorption, metabolism.
—Severe wasting or depressed growth.
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Parenteral
—Gastrointestinal incompetency.
—Hyper metabolic state with poor enteral tolerance or accessibility.
Step 3 Are nutrition goals being achieved?
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Set targets and check nutrition intake daily and act upon the findings.
•
It is recommended that calorie (and nitrogen) intake is calculated daily in addition to the
fluid balance. Has the patient received the amount of nutrition prescribed over previous
days?
The following guide illustrates the type of monitoring required:1) Fluid balance and calorie intake and if possible weight.
2) Urea and electrolytes daily (watch K+ as feeds may have only a modest K+ content)
3) Blood glucose monitored frequently and preferably as part of a tight glycaemic control.
4) Phosphate (This should be monitored closely especially when starting feeds in the
malnourished).
5) Plasma lipid clearance or triglycerides.
6) Full blood count.
7) Liver function tests, Calcium & Magnesium.
Critical Care Nursing
4TH Class 2013-2014
General concepts in caring for critically ill
2-Mechanical ventilation: - supportive therapy used to assist patients who are unable to maintain
adequate oxygenation or carbon dioxide elimination. These patients usually exhibit signs of acute
respiratory failure and are not candidates for less invasive methods of respiratory support.
-Acute Respiratory Failure:-defined as an acute onset of severely impaired gas exchange.
*Indications for Mechanical Ventilation:•
Cardiac or respiratory arrest
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Tachypnea or bradypnea with respiratory fatigue or
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Acute respiratory acidosis
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Refractory hypoxemia (when the P aO 2 could not be maintained above 60 mm Hg).
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Inability to protect the airway associated with depressed levels of consciousness.
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Shock associated with excessive respiratory work.
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Inability to clear secretions with impaired gas exchange or excessive respiratory work.
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Short term adjunct in management of acutely increased intracranial pressure (ICP).
*Type of Mechanical Ventilation:1-Non-invasive (if patient can protect airway and is hemodynamically stable)
-Mask: usually orofacial to start
2-Invasive
-Endotracheal tube (ETT).
-Tracheostomy – if upper airway is obstructed .
Diagram show how can use the types of M.V
Critical Care Nursing
4TH Class 2013-2014
General concepts in caring for critically ill
*Goals of Mechanical Ventilation:•
Improve ventilation by augmenting respiratory rate and tidal volume
1-Assistance for neural or muscle dysfunction
-Sedated, comatose or paralyzed patient
-Neuropathy, myopathy or muscular dystrophy
-Intra-operative ventilation
2-Correct respiratory acidosis, providing goals of lung protective ventilation are met.
3-Match metabolic demand.
4-Rest respiratory muscles.
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Correct hypoxemia
1-High F IO 2
2-Positive end expiratory pressure (PEEP)
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Improve cardiac function
1-Decreases preload.
2-Decreases afterload.
3-Decreases metabolic demand.
Critical Care Nursing
4TH Class 2013-2014
General concepts in caring for critically ill
*Artificial Airways:•
Endotracheal Intubation: - The most common tube used to provide an airway intubation
for mechanical ventilation is the endotracheal tube. It is inserted via the nasotracheal or
orotracheal cavity. Orotracheal intubation is the most common route. The endotracheal
tube provides a secure airway when the balloon is inflated and seals. Insertion is
moderately complex, but less invasive than a tracheostomy. Compared to the LMA, the
endotracheal tube provides greater protection from aspiration and air leaks.
3- Homodynamic monitoring:-is the study of the motion of blood through the body. In simple
clinical application this may include the assessment of a patient’s heart rate, pulse quality, blood
pressure, capillary refill, skin color, skin temperature, and other parameters.
*The purpose of haemodynamic monitoring: - is to obtain information that will indicate whether
the conditions that are required to maintain tissue perfusion are being maintained. The basis of
haemodynamic monitoring is the assessment of the adequacy of tissue perfusion. (The balance
between tissue oxygen demand and supply, as well as the maintenance of the nutritional,
temperature, and electro-chemical balances). The most fundamental of haemodynamic observations
is an assessment of end organ function.
*Example of Homodynamic monitoring:1- Arterial Lines:-Catheter placed in an artery to measure the Pressure from the artery by
(transmitted to a transducer by a column of fluid and converted in a pressure tracing).Transducer
must be placed at the Phlebostatic Axis – 4th intercostal space,Radial artery is the most common
site.
Phlebostatic Axis
Critical Care Nursing
4TH Class 2013-2014
General concepts in caring for critically ill
2- Pulmonary Artery Catheter (Swan-Ganz Catheter):-Catheter placed through a central vein to
the right atrium, right ventricle, and into the pulmonary artery to Evaluate heart disease, shock
states, compromised CO, and fluid status also used to evaluate a patient’s response to treatment,
and to measures Intracardiac Pressures and Cardiac Output. it consist of Pulmonary Artery Port,
Central Venous Port, Injected Port, Thermister Connection, and Balloon Inflation Valve.
3- Preload:-Volume within a cardiac chamber at the end of diastole. it use to measure Pulmonary
Capillary Wedge Pressure – estimates the left ventricular end-diastolic pressure, and Central
Venous Pressure – right ventricular end-diastolic pressure.
4- Afterload: - Refers to the forces that oppose ventricular ejection. Use to measure Systemic
arterial pressure, resistance of the aortic valve, mass and density of the blood and Systemic
Vascular Resistance.
5- Cardiac Output:-Volume of blood pumped by the heart in 1 minute, normal Cardiac Output 4-8
L/minute.
4- Sedation & Paralytic Therapy:a- Sedation:-relieve pain, decrease anxiety and agitation, provide amnesia, reduce patientventilator dysynchrony, decrease respiratory muscle oxygen consumption, facilitate nursing care.
Example of sedative agent is (Benzodiazepines)
*(Benzodiazepines)
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Diazepam (Valium), Lorazepam (Ativan),and Midazolam (Versed):
Critical Care Nursing
4TH Class 2013-2014
General concepts in caring for critically ill
*How we can Monitoring Sedation?
-by Ramsey scoring systems:
–
1: Anxious, agitated, restless
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2: Cooperative, oriented, tranquil
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3: Responds to commands
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4: Asleep, brisk response to loud sounds
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5: Asleep, slow response to loud sounds
–
6: No response
b- Analgesia: - The absence of pain through the use of pharmacotherapy.
*Pain
-Source of pain in critical ill phase (in ICU):•
Repeated episodes of acute pain localized.
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Surgery/tissue inflammation immobility.
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Catheter/ apparatus discomfort/ nasogastric & orogastric tubes.
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Endotracheal intubation/ suctioning/ chest tubes.
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Phlebotomy/vascular access/physiotherapy.
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Routine turning & positioning the patient.
-Types of pain (in ICU):•
Somatic – most common –localized  treated by opiates.
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Visceral – cramping & colicky  treated by anticholinergics .
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Neuropathic – burning / shooting  treated by antidepressants.
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Mixed type  treated by combination therapy.
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Sustained or chronic pain of varying degrees.
-Assessment of pain (in ICU):evaluation done by:
Pain as the 5th vital sign- requires frequent evaluation, this
 Cognitive impairment/delirium markers.
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Behavioral (facial, FACS)
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Physiological (BP, HR, RR)
 Creative assessments (teaching hand movements, blinking.
 Subjective quantification (numeric/graphic scales –W-B faces).
Critical Care Nursing
4TH Class 2013-2014
General concepts in caring for critically ill
numeric/graphic scales
- Treatment of Pain (in ICU): treatment of perceived & prevention of anticipated pain
 pharmacological: Opiates – principal agents in ICU
 non-pharmacological / multimodal therapies:

Simple Relaxation – must begin preoperatively:

Jaw relaxation

Progressive muscle relaxation

Simple imagery

Music (either patient – preferred or “easy listening” are effective in
reducing mild to moderate pain

Complex Relaxation – must begin preoperatively:

Biofeedback.

Imagery.
* Common Analgesic Drugs in the ICU:•
Morphine, Fentanyl, Remifentanil, Dilaudid, and Toradol .
c- Paralytics: - Paralytics are always given LAST
Paralysis: - loss of voluntary muscular function due to the administration of a paralytic
Neuromuscular Blockade Agent (NMB):- Drugs that obstruct transmission of nerve impulses to
the muscle this agent do not block the transmission of pain.
-why paralytics is use (in ICU)?
TO:
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Decreases O2 demand.
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Prevent Patient-Ventilator dyssynchrony.
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Prevents Shivering in hypothermia patients.
–
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Shivering increases O2 demand and Raises patients' temperature.
Open chest.
Critical Care Nursing
4TH Class 2013-2014
General concepts in caring for critically ill
- Common Paralytic agents are use (in ICU):
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Vecuronium, Pancuronium, Succinylcholine,and Nimbex.
5- Alteration in consciousness:•
Definitions
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Delirium: classically, altered awareness with motor and sympathetic hyperactivity,
often with sleeplessness, hallucinations, and delusions
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Obtundation: the patient appears to sleep much of the day but has some
spontaneous arousals
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Stupor: the patient lies motionless unless aroused but will awaken with
stimulation; localizes or withdraws from noxious stimuli
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Coma: the patient makes no understandable response to stimulation but may
display abnormal flexor (decorticate) or extensor (decerebrate) posturing.
Causes of a decreased conscious level:-Hypoxaemia, Hypotension, Hypercapnia,
Hypoglycaemia, Drugs (sedatives,opiates, overdoses,alcohol), Seizures, Head injury Intracranial
haemorrhage, Cerebral infarction, Intracranial infection, Hypothermia, Hyperthermia,
Hypothyroidism,and Hepatic encephalopathy .
-assessment level of consciousness by Glasgow Coma Scale:•
Best Eye Response. (4)
1. No eye opening.
2. Eye opening to pain.
3. Eye opening to verbal command.
4. Eyes open spontaneously.
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Best Verbal Response. (5)
1. No verbal response
2. Incomprehensible sounds.
3. Inappropriate words.
4. Confused
5. Orientated
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Best Motor Response. (6)
1. No motor response.
2. Extension to pain.
3. Flexion to pain.
4. Withdrawal from pain.
5. Localizing pain.
Critical Care Nursing
4TH Class 2013-2014
General concepts in caring for critically ill
6. Obeys Commands.
- Management of Deteriorating Conscious Level:•
Ensure the patient’s airway is patent
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Give high concentration oxygen to ensure good cerebral profusion
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If ventilation is inadequate, provide assisted ventilation.
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Ensure intravenous access and prescribe fluids as necessary
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Reverse any drug – induced CNS depression.
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Measure the blood glucose and treat if level is below 3mmol/l.
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Place patient horizontally in the left lateral recovery position.
6- Prolonged immobility: - critically ill patients are in our care, it is important to protect them
from further deterioration or delays in recovery. This is especially true for complications that are
not related to the underlying pathophysiology that brought the patient to the acute care facility.
Immobility is a well-recognized risk factor for a variety of adverse outcomes such as deep vein
thrombosis, decubiti, and pulmonary insufficiency.
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Immobility-Associated Complications
Critical Care Nursing
4TH Class 2013-2014
Decubitus ulcers
General concepts in caring for critically ill