Ventilation, ART lines, Care of the ICU pt, Infusion drip safety

What is TV? How much should a pt have?

Tidal Volume; Total amount of air being received

• less is more, especially in ARDS

• 4-8mg/kg of air volume

What is A/C?

Assist Control; A ventilator setting that does not remove the ability of the pt to breathe on their own

• MD sets minimum RR but pt can add breaths on their own

What is PEEP?

Positive End Expiratory Pressure; Setting on a ventilator where at the end of expiration, it gives an extra push to keep the alveoli open

• likely to drop BP/CO slightly as well

What is FiO2?

Fraction of inspired O2; The amnt of O2 the pt is actually getting

What is P/F ratio? What is it used for and what is the normal?

Ratio of PaO2 (Partial pressure of O2 dissolved in the blood) to FiO2

• Used to assess severity of hypoxemia

• Normal: >300

What are the problems with PEEP?

If it is raised too fast, it can lead to overdistention of the alveoli or cause them to rupture

How do you calculate P/F ratio?

PaO2 divided by FiO2 (Decimal version)

What is EtCO2? what is the normal?

It is a measurement of the partial pressure of CO2 at the end of respiration

• normal: 35-45

Why would EtCO2 increase?

• Hypoventilation

• Sepsis

• Fever, Shivering

• Acidosis

What is an Arterial line?

A way to monitor BP beat-to-beat by inserting a line into an artery

What care is required for an ART line?

• Frequent assessments of the site/tube

  • dressing should be clear, arm board should be removed

  • Perform neurovascular assessment (5 Ps)

  • Assess the connectors

• When not assessing, Immobilize extremity in a neutral alignment

• Ensure proper positioning of transducer - must be at the phlebostatic access

• Clearly label the tube

What are the potential complications of ART lines?

• Hemorrhage

• Infection

• Vessel Stenosis

• Loss of circulation distal to extremity

• Confusion with other lines?

How do you recognize the ART line complication hemorrhage?

• Blood spurting from site, hematoma forming near or at site, bruising

• Pain at site

• S/s of hypovolemic shock if severe blood loss

How do you recognize the ART line complication infection?

• Redness, warmth, pain at site

• Purulent drainage

• s/s of sepsis if it spreads

How do you recognize the ART line complication vessel stenosis?

• hemodynamic changes

• decreased oxygenation to distal extremity

How do you recognize the ART line complication loss of circulation?

• Cyanosis

• Cold skin

• 5 Ps: Pain, pulseness, paresthesia, paralysis, pallor

How do you recognize the ART line complication confusion with other lines?

• Dependent on the medication

• pain

• tissue death, ischemia

• vasospasm

What are the interventions for the ART line complication hemorrhage?

• Hold pressure immediately

• Call for help

What are the interventions for the ART line complication infection?

• DC line - keep tip for sampling

• Obtain blood sample

• Alert provider

• Monitor VS, perform neurovascular assessment

What are the interventions for the ART line complication stenotic vessell?

• Perform neurovascular assessments frequently

• Do not use the line if meeting resistance when flushing

• DC

What are the interventions for the ART line complication loss of circulation?

• DC line

• Alert provider

• Perform neurovascular assessments frequently

What are the interventions for the ART line complication confusion with other lines?

• DC infusion immediately

• Aspirate as much as possible

• Alert physician/Rapid response team

• perform neurovascular assessmnets

• Be prepared for emergency tx

When should ICU patients begin EN? Why?

• Within 24-48hrs of admit

• to aid with healing + prevention of skin ulcers

What is the range for blood sugars that ICU patients should be at?

140-180

What is a central line?

A line inserted into a large vein that has the tip by a big vein near the heart

How should CLs be cared for?

• Avoid changing dressing too often unless necessary

  • cleanse with CHG prior to removal

  • when changing, pt and nurse must wear masks and patient needs to look away

• Assess line and dressing frequently

• Check patency using a 10ml syringe, push meds in an appropriate sized syringe

• do not use if meeting resistance

• Document where the marking are to track if it has moved

Besides feeding and central line care, how should be ICU pt be cared for?

• Assess them frequently (at least every 2-4hrs)

• Keep O2 above 90% but avoid hyperoxygenating the pt

• Mobilize pt asap

  • ROM or PROM

• Remove invasive decides ASAP

What is delirium?

An acute change in brain function which causes confusion, inattention, change in LOC, and disorientation

How do you prevent/minimize delirium?

• Adequate pain control

• keeping pts possessions at the hospital (glasses, hearing aids)

• Communicating with pt even if they cant respond

• Prioritize letting them sleep

• Mobilize the patient

• medications

How can you prioritize letting the patient sleep in the ICU?

• Cluster care to avoid waking them up

• Set clear day/night schedule

• Melatonin for sleep deprivation

What medications can be used to minimize delirium?

• Propofol

• Ketamine

• Benzos (may actually increase delirium)

• Antipsychotics

  • haloperidol, seroquel, precedex

What are s/s of delirium?

• Brain dysfunction

  • inattention, confusion, or disorganized thinking

• fluctuating s/s

what are the s/s of hyperactive delirium?

• pt may try to pull out tubes

• attempting to get out of bed

• agitated or combative

What are the s/s of hypoactive delirium?

• may seem disengaged or distracted

• lack of facial expression

• lethargic

What is extravasation?

A complication of infusions where the fluid leaks into the tissue instead of the vein

What do you do if extravasation occurs?

1. DC the medication

2. aspirate out as much as possible

3. remove cannula

4. elevate extremity

5. place a warm, dry compress on site

6. use phentolamine ID or nitroglycerin paste

What is the CAM evaluation?

An assessment tool used to determine if a patient is presenting with delirium

What are the features of the CAM evaluation?

1. Acute onset or fluctuating course

2. inattention

3. disorganized thinking

4. altered LOC

Needs to have 1+2 or 3+4