CARING FOR CRITICALLY ILL PATIENT Role of a Critical Care Nurse Provide care direct to the patient. Involve family members in patient’s 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 co rrect 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.
Legal Relationships Nurse-employer
Nurse-patient Nurse-law
Nurses duty Competent & able to follow policies and procedures. Give reasonable and careful care 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. DNR order If patient is not for resuscitation, DNR should be documented by doctor. The doctor should explain everything to the patient about diagnosis and t reatment. PATIENT & FAMILY EDUCATION Nurses responsibility Assess patient & family learning n eeds. Education must be ongoing, interactive, and consistent with the education level. Reduce stress, anxiety, and fe ar 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)
Elements in Code of Ethics
The professional code of ethics Values and relationship among members of the profession and society. The purpose of the p rofession The need of profession to pro vide certain duties formed between nursing and society The standards of practice of the professional Describe specifics of practice in variety of settings and subspecialties.
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 pat ient.
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 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 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 Smoking Family history
Diabetes Male Obesity
Types of MI 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 in ferior wall
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
Special Consideration for: 1. Older adult 2. Sedated or unconscious patient 3. Illiterate patient 4. Noncompliant patient
Posterior MI •Occlusion in Rt coronary artery or circumflex artery •Tall R waves can be seen in leads V 1, 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
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, ne ck Shortness of breath Lightheaded Sweating Nausea and vomiting Risk Factors Middle to old age Family history Obesity Smoking Chronic Kidney disease
Stable Angina •
•
Complications of MI
Nursing Management Preventing co mplication -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 patient’s physical activity -Assess signs of heart f ailure (pedal edema) -Assess heart sound for new murmur. -Monitor patient for drug compliance -Give stool softener to prevent straining. Patient education -Eat variety of f ruit 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 d eep 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.
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.
•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
Types of angina
•
Related to electrical dysfunction New murmur Bradycardia Bundle branch block Heart block Related to contractility Heart failure Pulmonary edema Cardiogenic shock
Male Hyperlipidemia Hypertension Diabetes Post-menopause
Types of Heart Failure Left Ventricular Failure (LVF)
Unstable Angina •
•
•
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: Accurate assessment of chest pain to differentiate unstable & stable angina. Recognize myocardial ischemia by intensity of pain, vital signs, 12-lead ECG, and immediate fibrinolytic & heparin administered or PCI are performed to detect obstruction. Relieve chest pain by giving oxygen, nitroglycerin, analgesics, and aspirin. Maintain calm environment to reduce anxiety Patient education: -Alert nurse for any chest pain o r discomfort -Avoid straining -Risk factor modification -Identify signs & symptoms of angina -Importance of medication -When to call do ctors/seek treatment -Emotion & stress management HEART FAILURE Definition: A condition in which the heart cannot pump blood at a volume required to meet the body’s needs. Classification (based on symptoms & pt’s 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.
•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. 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.
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 & to xic 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 t reatment 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 c hambers of the heart.
Mitral Valve Stenosis Definition: 2 Narrowing of mitral valve orifice (<2cm ). The thickened, calcified valve cannot open or close passively, obstructing flow of blood from left atrium to left ventricle. Clinical Manifestation Dyspnea Chest pain
Fatigue Atrial Fibrillation
Diagnostic test: I. Chest X-ray: Pulmonary congestion, enlargement of main arteries & Lt atrium. II. ECG: Atrial fibrillation III. ECHO: Valve leaflet thickening & re stricted opening IV. Cardiac catheterization
Tricuspid Valve Regurgitation
Clinical Manifestation: Dyspnea Palpitation Paroxysmal nocturnal dyspnea
Fatigue Orthopnea Pulmonary venous hypertension
Diagnostic test: I. Chest X-ray: Left at rial enlargement and cardiomegaly II. ECHO Treatment Acute
IV Nitropruside to reduce afterload IV Nitroglycerin to reduce pulmonary pressures IABP to stabilize vital signs Mitral valve repair/ replacement
Chronic 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 o rifice which impedes the blood flow from heart to b ody. 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 se verity 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 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.
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: Backflow of blood from right ventricle into right atrium during systole. Diagnostic test: I. ECG: Incomplete right BBB II. Chest X-ray: Cardiomegaly III. ECHO: Identify the presence & severity Treatment: Tricuspid valve annuloplasty Tricuspid valve replacement.
Pulmonic Valve Disease 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 re lax and remain stiff in diastole. Clinical manifestation: Supraventricular tachycardia (SVT) Syncope Fatigue
Ventricular Tachycardia (VT) Shortness of breath Atrial Fibrillation
Diagnostic test: 1. Physical examination 2. Chest X-ray 3. ECHO 4. Genetic testing 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 Treatment: Sodium restriction Diuretics Tricuspid Valve Replacement
Definition: Characterized as dilation of both ventricles without muscle h ypertrophy. Types: Ischemic Familial
Repeated MI/ myocardial injury Idiopathic /genetic
Clinical Manifestation: Low cardiac output Fatigue Liver enlargement
Dyspnea Orthopnea Syncope
Restrictive Cardiomyopathy Definition: Characterized as ventricular wall rigidity due to myocardium scarring. Clinical manifestation: Shortness of Breath Palpitation
Edema Disrhythmia
Diagnostic test: + Physical examination + ECG + ECHO + MRI Treatment: Diuretics ACE inhibitor Exercise restriction SHOCK Definition: A serious, life thre atening medical condition where there is insufficient blood flow to meet tissues demand. Stages of shock Initial
•Hyperperfusion causes hypoxia. •Cellsperform anaerobic respiration leading to lactate & pyruvate build up causing metabolic acidosis. Compensatory
•Hyerventilate to clear CO2 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.
Monitoring: Non invasive Consciousness level Vital signs Oxygenation Infection signs Urine output Skin turgor Peripheral perfusion
ELECTROCARDIOGRAM (ECG) Invasive CO- Arterial line/ CVP Ventilator Urine output Arterial Blood Gases Blood results ECHO/ TOE
Treatment: Restoring blood volume and ensure oxygenation and blood p ressure adequate. -Normal Saline -Hartmann Solution Crystalloids -Dextrose solution -Albumin -Polygeline Colloids -Gelatin -Hetastarch -Blood products Airway managed & initiate oxygen the rapy Vasopressant to induce vasoconstriction Use anti-shock trousers to concentrate blood in vital organs (lungs, brain, h eart) Keep patient warm Antibiotics to prevent sepsis Adrenaline to stimulate cardiac performance Corticosteroid to reduce inflammation Trendelenburg position to shunt blood back to body’s core Chest tube to treat pneumo/hemothorax Thrombolysis to reduce size of clot. Pericardiocentesis to treat tamponade
P wave QRS complex T wave PR interval
Atrial contraction Ventricular contraction Ventricular relax AV node function
Definition: Sudden accumulation of blood, fluid, clots, pus or gas in pericardial space resulting in compression of heart muscle & interfere systole & diastole.
0.08-0.10 sec 0.06-0.10 sec 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 2 mm above
CARDIAC TAMPONADE
Clinical Manifestation: Tachycardia Hypotension Shock Restlessness
12 lead ECG consist of: a) 6 limb leads (I, II, III, aVR, aVL, aVF) b) 6 chest leads (V 1-V6) c) Standard speed of 25mm/second d) Small box = 0.04 sec = 1 mm e) Large box = 0.20 sec = 5 mm
1 mm below
Myocardial ischemia Myocardial infarction/ pericarditis Myocardial ischemia
QT interval
Indicates total time from onset of contraction to relaxation.
Difficulty in breathing Jugular vein distension Oliguria Dyspnea
Risk Factors: Blunt/ penetrating cardiac trauma Post cardiac catheterization Anticoagulant therapy Myocardial Infarction Acute pericarditis Management: Pericardiocentesis -Aspirate fluid from pericardial by needle Subxiphoid pe ricardiostomy -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
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.
HEMODYNAMIC MONITORING
ACUTE LUNG INJURY (ALI)
PNEUMONIA
Definition: Is the bedside measurement of the ever-changing pressure of blood flow through the cardiac, pulmonary & systemic vasculature via invasive catheters.
Definition: A systemic process of pulmonary manifestation which cause multiple organ d ysfunction syndromes. Severe ALI is known as Acute Respiratory Distress Syndrome (ARDS).
Definition: Acute inflammation of the l ung parenchyma
Benefits: Improve patient outcome Lower mortality rates Better quality of life after critical illness
Clinical Manifestation: Exudative phase
Measurement: Direct
Indirect (calculation)
CVP Rt Ventricle Pressure Pulmonary Artery P.
Tools: Intra-Arterial Catheters (IAC)
Central Venous Access Insertion site * Subclavian vein * Brachial vein Jugular vein
Pulmonary Artery Catheter (PAC) Insertion site * Subclavian vein * Jugular vein * Femoral vein * Brachial vein
Cardiac output Cardiac Index Lt Ventricular Ejection Fraction Lt Atrial Pressure Capillary Wedge P.
Purpose Measure MAP correctly Draw blood for ABG Monitor Arterial BP Insertion site * Radial artery * Femoral artery * Dorsalis pedis * Brachial artery * Axillary artery Purpose When peripheral site nor accessible For fluid resuscitation CVP monitoring Access for PAC Monitor blood circulation Purpose Measure pressure in both side of heart & pulmonary artery Measure CO Blood for mixed venous Fluid infusion Nursing intervention th at 4 ICS Zero transducer b4 read Supine/ Semi-fowlers Purpose Support in low CO & BP Post CABG Tranducer
Intra-aortic Balloon Pump (IABP) Insertion site * Femoral artery
Signs of complications ↓ Peripheral pulses ↓ Urine output Balloon migration ↑ temperature/ WBC ↓ Hematocrit (bleed) Weaning:
Hemodynamic stable No chest pain Adequate urine output
* * * *
Tachypnea Restlessness Anxiety Use accessory muscles
Risk factors: Direct Aspiration Drowning Toxic inhalation Pulmonary contusion Pneumonia Oxygen toxicity
Fibroproliferative phase * Agitation * Dyspnea * Fatigue * Use accessory muscle e xcessively * Fine crackles
Indirect Sepsis Trauma Hypertransfusion CABG Severe pancreatitis Embolism Shock
Pathophysiology After direct/ indirect injury, inflammatoryimmune 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 Diagnostic test: I. Arterial Blood Gases (ABG) -↓ PaCO2: Despite high oxygen demand -↑ PaCO2: Hyperventilation, fatigue -↓ pH: Respiratory acidosis II. Chest X-ray
Community Acquired Pneumonia (CAP) Pathogens -Strep. Pneumoniae -Legionella sp. -H. Influenzae -Staph. Aureus -Mycoplasma pneu. -Clamydia pneu. -Pseudomonas Risk factors Alcoholism COPD Diabetes Malignancy Coronary disease Clinical manifestation: Dyspnea Fever Cough Coarse crackles
Hospital Acquired Penumonia (HAP) Pathogens -Staph. Aureus -Strep. Pneumoniae -Pseudomonas -Aceno. Baumannii -Klesiella sp. -Proteus sp. -Serratia sp. Risk factors Elderly COPD Chronic illness Mecha. ventilation Smoking
Uremia Thrombocytopenia Hypoxemia Tachypnea
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
Management: Medical Mecha. Ventilation Low tidal volume (6ml/kg)- prevent Barotrauma Pemissive hypercapnia Increase CO2 slowly Oxygen therapy Tissue perfusion Adequate CO ↑ contractility Restrict fluid Diuretics
Nursing
Optimizing oxygenation & ventilation Preventing desaturation Promote secretion clearance Positioning Provide comfort & emotional support Prevent complications
Definition: Occurs when thrombotic embolus (clots) or nonembolus (fat, air, foreign bodies) stuck into the pulmonary arterial system, disrupting blood flow to the lungs. Pathophysiology When occluded, alveolar dead space ↑ ↑ work of breathing Hypercapnia & hypoxia causes bronchoconstriction ↑ pulmonary vascular resistance ↑ right ventricu lar workload
Clinical manifestation: Tachycardia Tachypnea Dyspnea Anxiety
Hemoptysis Cough Crackles Fever
Risk factors: Venous stasis (AF,↓ CO, immobility) Injury to vessels (infection, incision) Polycythemia Cardivascular disease (HF, cardiomyopathy) Cancer Trauma Pregnancy Diagnostic test:
Arterial Blood Gases (↓ PaCO2, ↓PaO2, ↑ pH) ECG (sinus tachycardia, BBB, AF) Chest X-ray (cardiomegaly, pleural effusion) Pulmonary angiogram DVT studies Management: Medical ~ Fibrinolytic agents (streptokinase) ~ Embolectomy ~ Anticoagulant (heparin or warfarin) ~ Inotropes ~ Fluid
Nursing Optimize ventilation & oxygenation ~ Monitor bleeding ~ Provide comfort ~ Prevent complications ~ Health education
PNEUMOTHORAX Definition: Accumulation of air between the parietal & visceral pleura with lung collapse. Types: 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 Management: 1.Oxygen therapy 2.Analgesics 3.Thoracocentesis 4.Chest tube 5.Thoracotomy- prevent recurrent
BASIC AIRWAY MANAGEMENT
MECHANICAL V ENTILATION
Oxygen administration: Types Nasal cannula Face mask Partial rebreather Non rebreather Demand valve Venturi mask (15 Lpm)
Definition: A mode of assisted or controlled ventilation using mechanical devices that cycle aut omatically to
Amount/percentage 2-6 Lpm/25-50% 6-10 Lpm/ 35-60% >10 Lpm/ >60% >10Lpm/ 60-95% 100 Lpm/ 100% With reservoir 50% No reservoir >95%
Intubation Techniques Head tilt, chin lift: Tongue may obstruct Jaw thrust: For s pinal 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 i njured -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: Hyperventilate patient or apply highconcentration of oxygen before suction Use sterile apparatus Maximum of 10 sec on each suction Be gentle Rotate the catheter when withdrawing it. Apply aseptic technique Use soft, flexible catheters Monitor for arrhythmia Attach oxygen after suction
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: 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 (60100 bpm). Require sedation •Used in hemodynamic instability, in shortterm 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 Respiratory Rate
Tidal Volume
Inspiratory flow
I:E ratio
PEEP FiO2
Inspiratory trigger
Modes used in delivering positive pressure. Number of breath ventilator delivers per minute (10-12/min) Volume delivered to patient during normal ventilator breath (7-10 ml/kg). Volume >10 ml/kg cause volutrauma. 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) Ratio comparing time delivering O2 and time to exhale (1:2). Positive pressure applied at end of expiration (3-5 cm H2O) Select delivery of O2 (21100%). Should be the lowest level to prevent oxygen toxicity. A control that adjust ventilator response to patient respiratory.
Criteria for starting mechanical ventilation: i. Respiratory rate >35 o r <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 mech anical 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 l ung 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, o verheating
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 doctor’s 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 patient’s respiratory status every sh ift: 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 o pposite 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 gast rointestinal 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: Prevent intubation Enhance alveolar ventilation ↓ work of breathing Improve gaseous exchange ↓ nosocomial infection Enhance patient comfort ↓ length of stay ↓ cost Indication AECOPD & respiratory failure Respiratory failure with h ypercapnia Respiratory failure with acute hypoxemia Asthma Methods: 1. Continuous Positive Airway Pressure (CPAP) o Air delivered via mask fit to p atient’s 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 cmH 20 2. Bilevel Positive Airway P ressure (BiPAP) o Provide higher positive pressure for inspiration o Enhance oxygenation & ventilation o Higher pressure is for inhalation (IPAP), lower pressure for e xpiration (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 Place hydrocolloid dressing face Mucosal Apply lip balm or nasal spray dryness Stomach Insert nasogastric tube distension Check for nausea, abdo Aspiration girth Serve antiemetic Corneal Ensure mask fit well Apply eye drop irritation Hypoventilate Ensure mask fit well
ARTERIAL BLOOD GASES (ABG) Interpreting ABG 1.Partial pressure of Oxygen (PaO 2) 2.pH level 3.Partial pressure of Carbon Dioxide (PaCO2) 4.Bicarbonate (HCO3)
Disorder
pH
Respiratory acidosis < 7.35 Uncompensated < 7.35 Partially Compensated normal Respiratory alkalosis > 7.45 Uncompensated > 7.45 Partially Compensated normal Metabolic acidosis < 7.35 Uncompensated Partially < 7.35 Compensated normal Metabolic alkalosis > 7.45 Uncompensated Partially > 7.45 Compensated normal Mixed < 7.35 Alkalosis Acidosis > 7.45 Causes: Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis Metabolic acidosis
PaCO2
HCO3
mmHg
mEq/L
> 45 > 45 > 45
normal > 26 > 26
< 35 < 35 < 35
normal < 22 < 22
normal < 35 < 35
< 22 < 22 < 22
normal > 45 > 45
> 26 > 26 > 26
> 45 < 35
< 22 > 26
~ Fever ~ Trauma ~ CNS infection ~ High altitude ~ Pneumothorax ~ Pregnancy ~ Airway obstruction ~ Pulmonary edema ~ Pneumonia ~ CNS depression ~ Neuromuscular impairment ~ Volume depletion ~ Bicarb administration ~ Diuretics ~ Diarrhea ~ Renal insufficiency ~ Rapid saline administration ~ Starvation ~ DKA ~ Lactic acidosis
BURNS Definition: Tissue damage caused by such agents as heat, chemicals, electricity, UV light or nuclear radiation. Leading cause of death is infection. Types Thermal Electrical Chemical Radiation
Causes Hot water, flammable liquid, explosion, fire Massive electrical current Strong acid/ alkali, mustard gas Exposure to UV light
Classification of burn Major 25% of TBSA 10% of TBSA full-thickness burn Deep burn (head, p erineum) 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
DIABETIC KETOACIDOSIS (DKA)
Degree of burns st 1 degree -Superficial burn -Causes pain, redness, swelling -Heal within 3-5 days n 2 degree -Partial thickness burn -Causes pain, swelling, blister -Heal within 10-14 days rd -Full thickness burn 3 degree -Causes black,char skin, numb -Heal within 30 days-months
Pathophysiology Hyperglycemia (absolute deficit in insulin)
Diagnosis test: Arterial Blood Gases Carboxy Hb level Coagulation studies Group Cross Match (GXM) Urine analysis Management: a) Resuscitative phase -Adult (> 15%), children (>10%) -Fluid resuscitation (Ringer’s Lactate): Parkland’s Formula (4 x BSA involved x body weight) st -50% given in 1 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 Nursing care: Strict intake & output chart Vital signs monitoring Pain assessment, administer analgesics Nutrition (high protein, enteral feeding)
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.
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 Clinical Manifestations: Hyperglycemia ↑ ketone level Polydipsia Polyuria Polyphagia Nausea & vomiting
Coma Shortness of breath Weakness Weight loss Abdominal pain 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 HYPERGLYCEMIA HYPEROSMOLAR NONKETOACIDOSIS SYNDROME (HHNS) Definition: Hyperosmolarity & severe hyperglycemia predominate with change of mental status due to insulin resistance. Occurs in type II DM. Pathophysiology 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 glu cose by urinating If patient do not consume enough water, it may results in severe dehydration
Clinical manifestations: Hyperglycemia Dehydration Excessive thirst Confusion
Polyuria Weakness Weight loss Fatigue
Risk factors: A. Poor DM control B. Non compliant to DM t reatment 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 fluid, * Administer insulin insulin, electrolyte * Restore electrolyte * Monitor compliant * Patent airway to therapy * Enough ventilation * Prevent & oxygenation complications * Close monitoring * Patient education Patient education for DKA & HHNS: a. Control blood sugar b. Consult doctor for b lood sugar level target c. Drink a lot of water d. Take medication as ordered e. Watch for signs & s ymptoms- Ketone in urine Comparison between DKA & HHNS DKA HHNS In type I DM In type II DM Sudden onset Slow onset Normal level ↑ ketone 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
Brain herniation
* Hyperventilate * Mannitol * Immediate CT brain * Contact neurosurgeon * Adequate pain control Thoracic trauma * Adequate oxygenation * Chest wall stabilization * Treat complication Pneumothorax * Chest tube insertion * Needle thoracostomy * High flow oxygen * Asherman chest seal Massive Tube thoracostomy hemothorax drainage * Thoracotomy * Adequate fluid volume Cardiac Pericardiocentesis temponade Maintain adequate volume Aortic rupture * Angiogram * Emergency endovascular stent graph CRIB Renal injury * Sedation * Observation (abd, girth) * IV fluid (major injury) * Antibiotic * Full laparotomy GI injury Debride devitalized tissue * Anastomoses if required * NGT suction * IV fluids External drainage Pancreatic * Control hemorrhage injury Liver injury Close monitoring * Blood transfusion * Laparotomy Spleen injury Close monitoring * Assess for bleeding * Splenectomy Apply compression belt/ Vertical Shear external fixator * Peritoneal aspiration * Urine catheterization * Suprapubic cystotomy * Bed rest Acetabular Traction * Reduce dislocation fracture * Operative reduction (if fail) Pelvic fracture Massive fluid replacement * Immobilization * Bleeding control Fat embolism Adequate oxygenation * Stabilizing hemodynamic * DVT prophylaxis * Early immobilization * Use corticosteroid & heparin reduce APO Cover with warm blanket Hypothermia * Warm IV fluid before infuse Shock Oxygenation * Arrest bleeding * Pneumatic antishock garment * Monitor vital signs, I/O, CVP, acid-base balance * Blood tranfusion
TRAUMA CARE IN EMERGENCY Triaging Categorising the patient according to treatment priority. A 24 hour basis by well trained Triage Officers. Triage criteria: Non-critical Walk-in & stable Semi-critical Hemodynamically stable but unable to walk Critical Critically ill, require immediate treatment. Zone & facilities: Resuscitation Resuscitation bays zone -Emergency treatment “golden hour” -Activation of trauma team Critical care bays -Observation & monitoring Immediate Immediate bays Care zone -Active bays for incoming semicritical Observation bays -Observation for semicritical 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 Victims of domestic violence, Crisis Centre rape, child abuse (OSCC) Registration done in the room by emergency staff Stabilization & transport of critically ill patient: Indication Contraindication Diagnostic purpose Increase potential risk Therapeutic purpose (surgery) Unstable/potential patient Specialized care (ED to ICU) 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 -Patient’s 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 -List of drugs to be used & infusion -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 Propofol
No analgesic properties + Lipid soluble + Interact with propranolol
Respiratory & CVS depression + Only in ventilated patient Butyrophenones Anti-psychotic tranquilizer * Haloperidol + In agitated, delirious &psychotic patient + Patient can develop EPS Analgesics Indication Relieve pain Common drugs Opiods * Morphine + Morphine- hypotension * Fentanyl + Fentanyl- expensive Non-opiods * Ketamine + Ketamine can cause * Ketorolac nightmares, hallucination & bronchodilate + Ketorolac side effect’s increase in critically ill & can cause renal failure.
Muscle relaxant/paralytics Indication For intubation In mechanical ventilation Prevent increase in ICP Reduce lactic acidosis Common drugs Eg: Succinylcholine Depolarizing agents NonEg: Pancuronium, depolarizing Vecuronium, Atracurium Vasopressors Indication
Increase contraction (β1) Vasodilate vessels (β2) Bronchodilate (β2) Vasoconstrict (α)
Common drugs Dopamine + Increase mesenteric blood flow + Risk of t achyarrhythmias Dobutamine + Primarily β1 + SVR may decrease + Useful in Rt heart failure + Risk of t achyarrhythmias Isoproteronol + Positive chronotrope + Increase HR & myocardial oxygen consumption + May worse ischemia PDE inhibitor * Milrinone + Positive inotrope & * Amrinone vasodilator + Little effect in HR + Used in CHF + Risk of t achyarrhythmia Adrenaline + Very potent agent + Effect on metabolic rate + Useful in anaphylaxis + Risk of coronary i schemia, renal vasoconstriction Noradrenaline + Potent α agent + Tend to spare brain & heart + Good in increasing SVR + Can cause reflex bradycardia Phenylephrine + Pure α 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 + α1 & β blocker Labetolol + Does not ↑ ICP + Used in HPT emergency, aortic dissection
