Critical Care Intro

ICU and CCU use the

zoom out approach

Ed uses a

zoom in approach

intermediate care

Judgement call to sick to be on number floor ratios, need more monitoring but not sick enough to be critical care p

neuro checks in critical care?

every 4 hours

ALOC

Q1H

Pain assessment

every 2 hours and with VS

VS per MD order and Q1H if on

vasoactive, antidysrhythmic or inotrope medications

Telemetry at all times, document

■rhythm at time of assessment

-Print and analyze strip every shift

If arterial line-

line-manual BP every shift

RASS/CAM ICU assessment every

shift

NG/OG check

Q4H with residuals

RAPID RESPONSE

Sudden deterioration in status

RR >30, <9

SpO2 <85% on O2**

HR >120, <30 without known reason

Systolic BP <90mmHg or >200mmHg

Urine Output <60mL/2 hours

Agitation, Delirium

Change in LOC/Stroke

ANY time staff, patient or family is worried

Mottling or Cyanosis

Call at first time of decline-DON'T WAIT

CODE BLUE

Not responsive

Not breathing

No Pulse

Agitation and delirium can not be treated until

pain is

ACUTE PAIN is

protective, self limiting, resolves with healing, (twist your ankle, touch a hot stove), treat the underlying problem (TRAUMA)

chronic pain is

nonprotective, ongoing persistent despite healing, irritability, depression, fatigue, Arthritis

NOCICEPTIVE PAIN

Somatic and Visceral, Pain with trauma or acute going on, comes from normal processes (breaking a bone), visceral pain (organs from an MI). throbbing, localized, treated with opioids/nonopioids

neuropathic

nerve damage , intense pain (pins and needles, (gabapentin) w diabetc pt

ways to assess for pain when pt cant communicate

•Behavioral Pain Scale (BPS)

•Critical-Care Pain Observation Tool (CPOT)

•Behavioral Pain Scale (BPS)

•Score of 3-12

•>5 pain that needs to be addressed and reassessed in 30 mins

•Presence of pain but not intensity

•Critical-Care Pain Observation Tool (CPOT)

•Score of 0-8

•>3 pain that needs to be addressed and reassessed in 30 mins

•Presence not intensity

Patient Controlled Analgesia (PCA)

•Self Administered at Safe Doses

•Small, frequent doses

Patient Controlled Analgesia (PCA) most common?

•Morphine and Hydromorphone

with PCA what is required

•2 RNs are required to check MD order and pump setting at each change in order, transfer and/or shift report. In addition to IV line. Document this.

•Loading Dose ____, Demand Dose ,Continuous Rate ____, Dose Limit per hour

(Bolus) (PCA rate), (Basal)

Patient Controlled Analgesia (PCA) assess

•Assess Q2H and PRN

■Sedation Agitation Scale

-1-7

-3 or 4 means calm or sedated

■Richmond Agitation Sedation Scale

-+4 - -5

-Completed every shift

-0 to -3 means calm to moderate sedation

+=agitated

-=lethargic

Rass score for pt on ventilator

-2

Agitation in Critical Care Patients

■Hyperactive patient movements that range in intensity

■Self harm, pulling on lines/tubes, physical aggression

■Caused By:

-Pain, Anxiety, hypoxia, ventilator dyssynchrony, positioning.....

USE RASS

delirium

ICU psychosis

Agitation can be a symptom of

delirium

anxiety treated with

benzos

delirium treated with

antipsychotics Haldol

Delerium test

■Cam ICU scale; completed every shift

delirium is due to

-Sepsis, critical illness, or other organ dysfunction (difficult to diagnose

haldol (haloperidol) MOA

Antipsychotic blocks dopamine mediated neurotransmissions at the cerebral synapses and basal ganglia

haldol (haloperidol) implications in ccu

-Prolongs QT interval (>0.44sec) cont. telemetry-dysrhythmias chaotic HR (on tele)

-Hypotension

-Tachycardia

■Sedation Vacation/Awakening trials

■ICU journal

■Redirection

■Music

■Family Presence at times

■Early Mobility (even when vented)

■Sleep Protocols

antidote for benzos

Flumazenil (Romazicon)

Antipsychotic can cause

extrapyramidal side effects tardive dyskinesia , somnolence

Agitation measure with

RASS score, take benzos , antianxiety

delirium measure with

CAMICU, impaired thought, decreased LOC, antipsychotics, reorientation, mobility

■Produced by a change in the environment that is perceived as threatening, challenging, or damaging to a persons equilibrium.

stress

stress activates the

ANS

sympathetic increases

your metabolism, it slows down the gut, increases your blood sugar,

Hyperglycemia in Critical Care Patients

■Insulin secretion is decreased = insulin deficiency compared to the need physiologically.

■Demand > Supply

■Needs are higher when ill/stressed

■Illness/Injury progresses the peripheral tissues may become insulin resistant

■1/3 of critically ill patients

Hyperglycemia in Critical Care Patients how to fix it

■140-180mg/dL ideal

-Minimize risk of hypoglycemia and avoiding extreme hyperglycemia

-Meeting higher demand

■150mg/dL start glycemic control

■Continuous insulin infusion

■POC blood glucose frequently

post intensive care syndrome

new or worsening impairment in physical, cognitive, or mental health status arising after critical illness and persisting beyond discharge from the acute care setting

muscle weakness, depression, nightmares, anxiety, cognitive problems, memory loss