Critical Care Nursing Review

THE CRITICALLY ILL PATIENT

Overview

  • Speaker: ZARENNA KHAN DNP, MSN-ED, BSN, MESDURGE-BC, PHN

  • Focus: Critical Care Nursing

  • Context: Chapter 65, Critical Care

Critical Care Units

  • Types of Units:
      - Critical Care Units (CCUs) or Intensive Care Units (ICUs)
        - Designed to meet special needs of acutely and critically ill patients
      - Progressive Care Units (PCUs)
        - Also called intermediate care or step-down units
        - Serve as a transition between ICU and general/unit care

  • Rapid Response Teams (RRTs):
      - Deliver advanced care through an interprofessional team

Role of the Critical Care Registered Nurse

  • Critical Care Registered Nurses (RNs) possess:
      - In-depth knowledge of anatomy, physiology, pathophysiology, and pharmacology
      - Advanced assessment skills
      - Ability to utilize advanced technology

  • Role of APRNs in Critical Care:
      - Function in multiple roles:
        - Educators (for both patients and staff)
        - Consultants
        - Administrators
        - Researchers
        - Expert practitioners

Common Problems of Critical Care Patients

  • Anxiety:
      - Includes perceived or expected threats to health or life

  • Pain:
      - Inadequate pain relief can lead to agitation, fear, anxiety, and stress response

  • Impaired Communication:
      - Caused by sedatives, endotracheal (ET) tube placement, or neurological impairments

  • Sleep Disturbance:
      - Difficulty falling asleep or disrupted sleep due to treatments, monitoring, or care needs

  • Sensory-Perceptual Problems:
      - Acute and reversible sensory-perceptual changes are common in ICU patients
      - Recommendation: Cluster care activities to provide uninterrupted rest periods

Supporting Caregivers

  • Caregivers need support in various ways:
      - Linking patients to the outside world
      - Facilitating decision-making and advising patients
      - Assisting with daily activities
      - Acting as liaisons to advise healthcare teams
      - Providing safe, caring, and familiar relationships

  • Major needs of caregivers include:
      - Information
      - Communication
      - Access

  • In emergencies, ask families if they wish to remain at the bedside

Hemodynamic Monitoring

  • Purpose:
      - Assess heart function, fluid balance, and effects of fluids/drugs on cardiac output

  • Measurements Include:
      - Systemic and pulmonary arterial pressures
      - Central venous pressure (CVP)
      - Pulmonary artery wedge pressure (PAWP) or Pulmonary artery occlusive pressure (PAOP)
      - Cardiac output (CO) and cardiac index (CI)
      - Oxygen saturation of arterial blood (SaO2) and mixed venous oxygen saturation (SvO2)

Hemodynamic Technology

  • Cardiac Output (CO):
      - Volume of blood in liters pumped by the heart in one minute
      - Normal range: 4−8extL/min4-8 ext{L/min}

  • Cardiac Index (CI):
      - CO adjusted for body surface area (BSA)
      - Normal range: 2.8−4.2extL/min/m22.8-4.2 ext{L/min/m}^2

  • Systemic Vascular Resistance (SVR):
      - Opposition encountered by the left ventricle
      - Normal range: 900−1400extDynes900-1400 ext{Dynes}

  • Pulmonary Vascular Resistance (PVR):
      - Opposition encountered by the right ventricle
      - Normal range: 100−250extDynes100-250 ext{Dynes}

Preload and Afterload

  • Preload:
      - Volume within the ventricle at the end of diastole
      - Left ventricular preload measured by left ventricular end-diastolic pressure (PAWP)

  • Afterload:
      - Forces opposing ventricular ejection, including systemic arterial pressure, resistance from the aortic valve, and blood density

Vascular Resistance and Contractility

  • SVR and PVR:
      - Resistance of systemic and pulmonary vascular beds respectively, reflecting afterload

  • Contractility:
      - Strength of heart contraction
      - Increased by positive inotropes like epinephrine, norepinephrine, digoxin, and dopamine
      - Decreased by negative inotropes such as beta-blockers and calcium channel blockers

Principles of Invasive Pressure Monitoring

  • Equipment must be referenced and zero balanced to the environment

  • Referencing:
      - Positioning transducer so zero reference point is level with the atria of the heart or phlebostatic axis

  • Zeroing:
      - Confirms accurate monitor readings at zero pressure within the system

  • Dynamic Response Test:
      - Perform every 8 to 12 hours, when the system opens to air, or when accuracy is in question

Positioning the Zero-Reference Stopcock

  • Mark the location of the phlebostatic axis on the patient’s chest

  • Re-check zero-reference stopcock alignment with changes in patient position

  • Misplaced transducers lead to inaccurate BP readings:
      - Higher position results in lower BP readings
      - Lower position results in higher BP readings

Types of Invasive Pressure Monitoring

  • Arterial Blood Pressure (ABP):
      - Continuous monitoring indicated for acute hypotension, hypertension, respiratory failure, shock, and neurologic injury
      - Use for arterial blood gas collection
      - Complications: hemorrhage, infection, thrombus formation, catheter migration
      - A-lines are not for medication infusion!

  • Pulmonary Artery Flow-Directed Catheter:
      - Measures pressure sensitive to heart function and fluid volume status
      - Indicators: PADP and PAWP
      - Changes in these values indicate heart failure or fluid overload

Normal Pressure Ranges

  • Right Atrium (CVP/RAP): 2–6extmmHg2–6 ext{ mmHg}

  • Right Ventricle Systolic/Diastolic: 15–25extmmHg/0–8extmmHg15–25 ext{ mmHg}/0–8 ext{ mmHg}

  • Pulmonary Artery Systolic/Diastolic: 15–25extmmHg/5–15extmmHg15–25 ext{ mmHg}/5–15 ext{ mmHg}

  • Pulmonary Artery Mean: 9–16extmmHg9–16 ext{ mmHg}

  • Pulmonary Capillary Wedge Pressure (PCWP/PAWP): 4–12extmmHg4–12 ext{ mmHg}

Central Venous Pressure Management

  • CVP Measurement:
      - Indicates right ventricular preload and fluid volume status
      - Measured as mean pressure at end of expiration

  • Normal CVP Range: 2−6extmmHg2-6 ext{ mmHg}
      - High CVP indicates right ventricular failure; low indicates hypovolemia

Venous Oxygen Saturation Monitoring

  • Measures O2 saturation in venous blood to assess tissue oxygenation adequacy

  • Normal Ranges:
      - Mixed venous saturation (SvO₂): 60% to 75%
      - Central venous saturation (SCVO₂): generally 5% higher than SvO₂

Mixed Oxygen Saturation Causes

  • Low Mixed Venous Oxygen Causes:
      - Low CO/CI, low hemoglobin and hematocrit, low SaO2, high O2 demand

  • High Mixed Venous Oxygen Causes:
      - Heavy sedation, hypothermia

Noninvasive Monitoring

  • Pulse Oximetry:
      - A continuous noninvasive method to determine O2 saturation of hemoglobin (SpO2)

  • Impedance Cardiography:
      - Noninvasive method to obtain CO and assess thoracic fluid status
      - Helps detect early signs of problems, guides interventions post PA catheter removal, and is used to evaluate drug therapy and transplant rejection

Nursing Management: Hemodynamic Monitoring

  • Obtain baseline data regarding the patient’s condition:
      - General appearance, level of consciousness, skin color, pulses, capillary refill, etc

  • Monitor for deviations from normal baseline

Noninvasive Ventilation Types

  • Continuous Positive Airway Pressure (CPAP):
      - Prevents airway pressure from dropping to 0 during spontaneous breathing; used for obstructive sleep apnea

  • Bilevel Positive Airway Pressure (BiPAP):
      - Provides two levels of support (higher for inhalation and lower for exhalation); used for COPD, heart failure, and acute respiratory failure

Artificial Airways

  • Endotracheal (ET) Tubes:
      - Inserted through the mouth into the trachea with a laryngoscope

  • Intubation Procedure:
      - Consent obtained unless emergent
      - Use ETCO2 detector to confirm placement

  • ABG Testing:
      - Should be obtained 15 to 30 minutes post-intubation to assess oxygenation and ventilation status

Nursing and Interprofessional Management: Artificial Airway

  • Shared responsibilities between RN and Respiratory Therapist (RT):
      - Maintain correct tube placement and cuff inflation
      - Monitor oxygenation and ventilation
      - Keep the head of the bed at a 30-45 degree angle
      - Ensure tube patency, provide oral care, and maintain skin integrity
      - Foster comfort and communication, monitor for complications (unplanned extubation or aspiration)

Mechanical Ventilation

  • Types of Ventilation:
      - Negative Pressure: Utilizes sub-atmospheric pressure; used for COPD and neuromuscular disorders
      - Positive Pressure: Main method for critically ill patients; pushes air into the lungs

Complications of Positive Pressure Ventilation

  • Can affect multiple body systems, including:
      - Cardiovascular issues
      - Pulmonary complications (e.g., ventilator-associated pneumonia)
      - Psychosocial issues (e.g., anxiety, stress)
      - Neurological (impaired cerebral blood flow)
      - Electrolyte imbalances (sodium and water)
      - Gastrointestinal (stress ulcers)
      - Musculoskeletal (immobility, contractures, muscle wasting)

Weaning from Positive Pressure Ventilation and Extubation

  • Weaning Process:
      - Reducing ventilator support; can take up to 3 days for short-term ventilations, may exceed 3 days for long-term

  • Preparing for Extubation:
      - Patient should receive hyperoxygenation and suctioning before extubation

Chronic Mechanical Ventilation

  • Mechanical ventilators for long-term home care

  • Criteria for Discharge on Mechanical Ventilation:
      - Tracheostomy, stable mechanical ventilation settings

  • Advantages:
      - Less stress in home environment

  • Disadvantages:
      - Equipment issues, caregiver stress, complexity of patient needs

NCLEX Questions and Rationales

  • Question about sensory perception and sleep deprivation in ICU:
      - Correct Answer: B (Cluster nursing activities for uninterrupted rest to minimize disruption in sleep cycles)

  • Question on family during resuscitation:
      - Correct Answer: B (Families often prefer to remain present during CPR, which reduces anxiety)

  • Question concerning low CVP post-abdominal aortic aneurysm surgery:
      - Correct Answer: B (Increased IV fluid infusion is needed for hypovolemia)

  • Question on arterial pressure monitoring:
      - Correct Answer: B (Positioning the zero-reference stopcock correctly ensures accurate pressure measurement)

  • Question on arterial line assessment:
      - Correct Answer: A (Coolness of the right hand indicates potential impaired blood flow)

  • Question for ET tube placement verification:
      - Correct Answer: B (End-tidal CO2 monitoring is the most accurate method for verification)

  • Question indicating the need for suctioning:
      - Correct Answer: C (Increased respiratory rate suggests decreased airway clearance, necessitating suctioning)

To help you with an ATI-style question based on the material covered in the first week, here's an example:

Question: A patient in the ICU is experiencing increased anxiety and impaired communication due to the placement of an endotracheal (ET) tube. Which of the following nursing interventions should the critical care nurse implement to address these issues?

A) Administer sedative medications to the patient.

B) Use nonverbal cues and gestures to communicate effectively.

C) Encourage the patients’ family to leave the bedside.

D) Avoid discussing the patient’s condition until the ET tube is removed.

Correct Answer: B) Use nonverbal cues and gestures to communicate effectively.

Rationale: Effective communication is crucial for patients with impaired communication abilities. Utilizing nonverbal cues and gestures can help alleviate anxiety and maintain the patient's sense of involvement in their care.

  • Question about sensory perception and sleep deprivation in ICU:

    • Correct Answer: B (Cluster nursing activities for uninterrupted rest to minimize disruption in sleep cycles)

  • Question on family during resuscitation:

    • Correct Answer: B (Families often prefer to remain present during CPR, which reduces anxiety)

  • Question concerning low CVP post-abdominal aortic aneurysm surgery:

    • Correct Answer: B (Increased IV fluid infusion is needed for hypovolemia)

  • Question on arterial pressure monitoring:

    • Correct Answer: B (Positioning the zero-reference stopcock correctly ensures accurate pressure measurement)

  • Question on arterial line assessment:

    • Correct Answer: A (Coolness of the right hand indicates potential impaired blood flow)

  • Question for ET tube placement verification:

    • Correct Answer: B (End-tidal CO2 monitoring is the most accurate method for verification)

  • Question indicating the need for suctioning:

    • Correct Answer: C (Increased respiratory rate suggests decreased airway clearance, necessitating suctioning)

To help you with an ATI-style question based on the material covered in the first week, here's an example: Question: A patient in the ICU is experiencing increased anxiety and impaired communication due to the placement of an endotracheal (ET) tube. Which of the following nursing interventions should the critical care nurse implement to address these issues? A) Administer sedative medications to the patient. B) Use nonverbal cues and gestures to communicate effectively. C) Encourage the patients’ family to leave the bedside. D) Avoid discussing the patient’s condition until the ET tube is removed. Correct Answer: B) Use nonverbal cues and gestures to communicate effectively. Rationale: Effective communication is crucial for patients with impaired communication abilities. Utilizing nonverbal cues and gestures can help alleviate anxiety and maintain the patient's sense of involvement in their care.