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Critical Care Nursing 4TH Class 2013-2014 General concepts in caring for critically ill Component of literature • Nutritional support. • Mechanical ventilation. • Homodynamic monitoring. • Sedating and paralytic agents. • Alteration in consciousness. • Pain. • 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. • Improved gastrointestinal structure and function. • 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? • Step 2 ADMINISTRATION which route(s) should be used? • 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. • Parenteral —Gastrointestinal incompetency. —Hyper metabolic state with poor enteral tolerance or accessibility. Step 3 Are nutrition goals being achieved? • 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 • Tachypnea or bradypnea with respiratory fatigue or • Acute respiratory acidosis • Refractory hypoxemia (when the P aO 2 could not be maintained above 60 mm Hg). • Inability to protect the airway associated with depressed levels of consciousness. • Shock associated with excessive respiratory work. • Inability to clear secretions with impaired gas exchange or excessive respiratory work. • 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. • Correct hypoxemia 1-High F IO 2 2-Positive end expiratory pressure (PEEP) • 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) • 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 – 2: Cooperative, oriented, tranquil – 3: Responds to commands – 4: Asleep, brisk response to loud sounds – 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. • Surgery/tissue inflammation immobility. • Catheter/ apparatus discomfort/ nasogastric & orogastric tubes. • Endotracheal intubation/ suctioning/ chest tubes. • Phlebotomy/vascular access/physiotherapy. • Routine turning & positioning the patient. -Types of pain (in ICU):• Somatic – most common –localized treated by opiates. • Visceral – cramping & colicky treated by anticholinergics . • Neuropathic – burning / shooting treated by antidepressants. • Mixed type treated by combination therapy. • 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. • Behavioral (facial, FACS) • 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: • Decreases O2 demand. • Prevent Patient-Ventilator dyssynchrony. • Prevents Shivering in hypothermia patients. – • 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): • Vecuronium, Pancuronium, Succinylcholine,and Nimbex. 5- Alteration in consciousness:• Definitions • Delirium: classically, altered awareness with motor and sympathetic hyperactivity, often with sleeplessness, hallucinations, and delusions • Obtundation: the patient appears to sleep much of the day but has some spontaneous arousals • Stupor: the patient lies motionless unless aroused but will awaken with stimulation; localizes or withdraws from noxious stimuli • 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. • Best Verbal Response. (5) 1. No verbal response 2. Incomprehensible sounds. 3. Inappropriate words. 4. Confused 5. Orientated • 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 • Give high concentration oxygen to ensure good cerebral profusion • If ventilation is inadequate, provide assisted ventilation. • Ensure intravenous access and prescribe fluids as necessary • Reverse any drug – induced CNS depression. • Measure the blood glucose and treat if level is below 3mmol/l. • 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. - Immobility-Associated Complications Critical Care Nursing 4TH Class 2013-2014 Decubitus ulcers General concepts in caring for critically ill