124 notecards = 31 pages (4 cards per page)
Common treatment in critical care:
Concerned w/human responses to life-threatening problems, such as: trauma, major surgery or complications
Healthcare system driven by the needs of patients and families, in which critical care nurses make optimal contributions, which is described as synergy.
Standards for critical care nursing:
Patient & family
Family can sometimes be a burden for patients. Advocacy is a major role a nurse must face when caring for critical patients.
Noise & sleep deprivation equal environmental factors when caring for patients.
Effects of noise
* Noise can also cause med errors due to distractions
* Use sedative music to help relax patient
Critical care: PTSD
Is common after critical care is given. Primary goal in nursing interventions is to increase safety, reduce sleep deprivation & minimize sensory overload.
* Give clustered care for ↑ rest periods
* DO NOT ASK "Do you know where you are?" Just reorient q2-4ºto maintain dignity of patient.
Stress caused when transferring patient to another unit
______ ______ method is the best way to evaluate understanding of families & patients.
Critical care: Elderly
They are at greater risk for negative outcomes. This is caused for many losses in life an elderly patient has suffered before hospitalization.
Information related to family's developmental stage, task & attachment
Reveal how family members function and behave in relation to one another.
Cultural assessment questionaire
Most common needs for families
*Nurses can assist in promoting policy changes to affect open visitation policies when needed
Family observing invasive procedures
By doing so results in:
↑ knowledge of pts condition
↓ fear & anxiety
Visual analog pain scale (VAS)
Used to help rate pain & anxiety
Behavioral pain scale
Each item is rated 1-4.
Facial expression- relaxed scores=1
Facial expression- grimacing = 4
Upper limbs- No movement= 1
Upper limbs- full bent w/finger flexion= 3
Upper limbs-Permanently retracted= 4
Compliance w/ventilation- tolerating movement= 1
Compliance w/ventilation- fighting ventilator= 3
Compliance w/ventilation- Unable to control ventilation= 4
Critical care pain observation tool
Score rate from 0-2 (0=good)
Relaxed, no muscle tension= 0
Tense facial muscle= 1
Grimacing w/tense facial muscles= 2
Critical care pain observation tool
No sound = 0
Sighing, moaning = 1
Crying out, sobbing = 2
Richmond agitation sedation scale (RASS)
A 10 point scale, from 4- combative through 0- calm & alert, to -5 which is unarousable. The patient is asses for 30-60 seconds in the three steps, using discreet criteria.
* Useful in detecting changes in sedation status over consecutive days of critical care unit.
Ramsey sedation scale
Was developed for evaluation of postoperative patients emerging from general anesthesia.
This scale includes 3 levels of wakefulness & 3 levels of sedation.
1 = Pt. awake, anxious & agitated or restless
3 = Pt. awake, responds to commands only
4 = Pt. asleep, brisk response to light tap or
loud auditory stimulus. (lightest sleep)
6 = Pt. asleep, no response to light tap or loud
auditory stimulus (complete sedation)
Sedation agitation scale
describes pt. behaviors seen in the continuum of sedation to agitation. Scores range from 1 (unarousable) to 7 (dangerously agitated).
* Goal- Keep patient safe
* Drug of choice- haloperidol
Delirium (acute brain dysfunction)
Characterized by an acutely changing or fluctuating mental status-
* I nattention
* Disorganized thinking
* Altered levels of consciousness
Delirium 3 clinical subtypes
1. Hypoactive: Quiet delirium, can go undiagnosed. Most prevalent, occurring in more than 60% of patients.
2. Hyperactive: Combative, agitated, disoriented. *hallucination, paranoia & delusions may be seen too** Extremely rare
3. Mixed: describes the fluctuating nature of delirium.
ABCDE Bundle for preventing Delirium:
Neuromuscular Blockade (NMB)
In operating room & critically ill pt.'s to facilitate endotracheal intubation and mechanical ventilation, to control increases in intracranial pressure & to facilitate procedures at the bedside (bronchoscopy, tracheostomy)
Neuromuscular Blockade (NMB):
Complete chemical paralysis
Neuromuscular Blockade (NMB)
Succinylcholine - short term use
agents do not possess any sedative or analgesic properties. Any patient receiving these agents must also be sedated!
Pt.s receiving effective NMB is not able to communicate or produce any voluntary muscle movements, including breathing.
Nursing care of a patient receiving NMB
A peripheral nerve stimulator to assess the level or degree of paralysis.
Evaluates the level of NMB to ensure that the greatest amount of NMB is achieved with the LOWEST dose of NMB medication.
TOF how it works
The peripheral nerve stimulator delivers 4 low energy impulses and the number of muscular twitches is assessed.
* 4 twitches of the thumb or facial muscle indicate incomplete NMB.
* The absence of twitches indicates complete NMB. TOF goal is 2 out of 4 twitches
* The ulnar nerve & the facial nerve are the most frequently used sites for peripheral nerve stimulation. *
Common beliefs of the healthcare system
Who speaks for the patient?
A. Surrogate decision making
A. Healthcare surrogate- Appointed by pt. (POA)
B. No family & cannot make decision themselves
Dimensions of nursing care at end of life:
Common symptoms at end of life
*Pt.'s when dying tend not to be hungry- GI slows down & doesn't process food, they feel full and don't want to eat.
Nursing interventions for Palliative care (in critical condition- not dying yet)
Palliation: Elements of Palliative care:
- Relieve pain (warm blanket is good)
- Control anxiety
- Control other distressing symptoms
Communication & conflict resolution
Withholding, Limiting, or Withdrawing treatment
Withdrawal of treatment
Discontinuation of life-sustaining therapies in a terminally ill or persistently vegetative patient.
Withholding of treatment
Failure to initiate life-sustaining therapies in a terminally ill or persistently vegetative patient.
Common withdrawal- Terminal weaning (intubation), start morphine IV drip & titrate for comfort- then remove tube.
- Relieves tachypnea, dyspnea, and use of accessory muscles
Ethical principles related to withdrawal & withholding of treatment:
Other commonly withheld therapies:
Other commonly withheld therapies: Vasopressors
Also Glucocorticoids and mineralocorticoids
* Digoxin too!
Commonly withheld therapies: Antibiotics
Commonly withheld therapies: Blood & blood products
* Fresh frozen platelets
Commonly withheld therapies: Nutritional support
Nursing interventions during withdrawal or withholding of treatment:
Comfort & sedation: Introduction
Pain & Anxiety:
- Patient feelings of powerlessness
- Mental status changes: Agitation, Delirium, ICU psychosis
Predisposing factors of pain:
- Previous pain experiences
- Emotional state
- Cognitive status
Predisposing factors of anxiety
- Endotracheal tube- pt. gagging or coughing, needs adjustment- it's better for the tube to be placed on either side of the mouth. If needs adjustments call respiratory.
- Monitor alarms
- Lack of mobility
- Unfamiliar surroundings
- Sleep deprivation
Physiology of pain: Nociceptors
- Mechanical stimuli= surgery or wound, pinching or crushing
- Chemical stimuli= Burn, chili pepper in the eyes, acid burns
- Thermal stimuli- Heat and cold stimulation
Physiology of Anxiety
Positive effects of pain/anxiety:
Negative effects of pain/anxiety
Five-Step assessment of pain: American pain society guidelines
Subjective assessment tools: Characteristics of pain
This is what you would ask patient regarding their pain, during your assessment.
P= provocation or position
Q= quality (sharp, dull, aching)
R= radiation (does is travel to other parts of the body)
S= severity or associated symptoms
T= timing or triggers
Subjective Assessment tools:
Series of faces from happy to distressed- you can have them point
Visual analog scale (VAS)
- Patient points to a level of pain severity on a 10cm line
- Can also be done w/pencil to mark severity
Objective assessment tools:
For patient who cannot communicate, no objective tool completely reflects patients' pain level
Behavioral pain scale: Scored items
There are 3:
Each item is graded 1-4;
1= Relaxed, no movement or Tolerating movement
4= Grimacing, Permanently retracted or unable to control ventilation.
Critical-care pain observation tool: Scored indicatiors
There are 5 scored categories & each are graded from 0-2, add each category for a total overall score.
0= Absence of or tolerating well, 2= Grimacing, fighting or restlessness
* Must be sedated- can cause mental trauma
* No sedative or analgesic properties- Must provide sedation!!!
Peripheral nerve stimulator
* 4 twitches of the thumb or facial muscle = incomplete NMB
* The absence of twitches indicates complete NMB
* TOF Goal is 2 out of 4 twitches.
Nursing care NMB
- Mechanical ventilation & airway management
- Eye lubrication
- DVT prophylaxis
- Repositioning and range of motion
- Oral care
- Urinary catheter
- Routine vital signs & assessments
management of pain and anxiety: Nonpharmacological management
Management - Opioids
- Fentanyl= Fastest onset- available in patch too
- Morphine= Longer duration
- Hydromorphone- Dilaudid
Management -Opioids: Concerns
* Respiratory depression- monitor breathing & O2 sats
* Hypotension- sit up slowly, fall risk, dizziness
* Check platelet level, if low hold ASA- Ask doctor
- propofol- knocks you out!
- Dexmedetomidine (Precedex)- sedative for procedures!
Patient- Controlled Analgesia
* Elective surgery
* Large surgical or traumatic wounds
* Normal cognitive function
* Normal motor skills
* So obviously someone who is in a coma, or delirious would not be a good candidate for a PCA.
- May have higher than normal threshold to pain meds- it's not the pain itself
- Alcohol withdrawal syndrome (AWS)- higher tolerance for pain meds as well
Management challenges: Elderly
- Comorbidities- multiple health issues
- Multiple medications- for the multiple health issues!
- Physical frailty
- Cognitive or sensory deficits- Cannot hear, get confused, or cannot see very well.
All critically ill patients are assumed to be at ____________ risk.
Utilizations of nutrients: Cell require-
- Secretes intrinsic factor for vitamin B12
- Secretes fluids high in Na+ and K+
-pancreas & liver empty here
Glucose & water-soluble vitamins absorbed
- protein broken down & absorbed
- Absorbs fat-soluble vitamins
Secretes digestive enzymes
Assists in emulsifying fats
decreased level you will edema
Most accurate measurement for weight
Nutritional therapy goal: Any pt who cannot meet needs orally for __ or more days requires nutritional support
Nutritional therapy goal:
Obvious damage or trauma
nutritional support within 24hrs
Nutrition care plan
- Pt.'s calorie, protein, and fluid needs
- Intake targets
- Route of administration
Set measurable short & long term goals
- Weight gain
- Stable laboratory values * with propofol must look at triglycerides labs- it's lipid based!
- Lower risk of infection
- Less expensive
*After placement of PEG tube, button is tight to prevent/stop bleeding; loosen after a while to prevent skin breakdown.
- High protein
- Fiber enriched
- Wound healing
Guidelines for Enteral feeding:
Short-term enteral feeding
Guidelines for Enteral feeding:
Long-term enteral feeding
- Gastrostomy tube
- Jejunostomy tube
- intermittent: gastric
- Continuous: small bowel feedings- acute care settings.
Assess gastric residuals
- How? How often?- With an irrigation syringe and every 4hrs
What is significant? - Residual, too much means pt. is not tolerating feeding. Hold per policy if 200mL or more & put it back.
- Differences between gastric & small bowel locations- vomit & aspirate
Flush feeding tube with ____ of water
Tolerance of Enteral nutrition (EN)
Signs of intolerance to EN
Guidelines for Parenteral nutrition
Feeding delivered into bloodstream
- Central line (TPN)= hypertonic
- Peripheral line (PPN)= isotonic
Central line= hypertonic fluids
Peripheral line= isotonic fluids
The nurse would suggest oral or enteral feedings for which patient?
Parental Nutrition: Indications
Used for patients who are unable to tolerate enteral feeding
- GI obstruction
- Intractable vomiting or diarrhea
- NPO for an extended period of time (>1wk)
Patients who are admitted very malnourished
- start immediately, if unable to tolerate enteral feeding.
Unable to meet nutritional demands with EN
Parenteral nutrition: complications
Monitor for complications
- Infection (sepsis)
- Electrolyte imbalances
- Fluid imbalances
- Hyperglycemia (TPN contains insulin)
Hold enteral feeding when giving _____ because it will cause a reaction.
Nursing Care for enteral & parental feedings
EN & PN complications
Preventing complications: EN & TPN
EN/TPN- Monitoring & evaluating
- Begin at the initiation of therapy
- Stable patient assessed every week
- Critically ill patient assessed more often