1

Elec II: Acute/Critical Care Nursing

Critical Care Nursing
NELT 102 Acute/Critical Care Nursing
Course Description: This course is
designed to introduce the student to
care for critically ill patients. Emphasis
is on rapid assessment, setting
priorities, rapid decision making and
appropriate nursing interventions. This
course may include cases with
cardiovascular, pulmonary, renal,
neurologic, and multi-system
alterations.

Ethical Principles in Critical Care

Patient Autonomy: Self
determination, freedom of choice
Justice: Fair treatment without
discrimination
Veracity: Truth, honesty and integrity
Fidelity: Obligation to care to the best
of ones ability
Beneficence: Doing good for others
Non-maleficence: Do no harm
Paternalism: Deciding what is right
(best) for others
Critical Care Nursing deals with:

Critical Care

A service for patients with potentially

recoverable diseases who can benefit
from more detailed observation and
treatment than is generally available in
the standard wards and department.

Critical care settings:

Intensive care
High Dependency Unit
Progressive Care Unit
Outreach Care

Intensive Care Unit: Reserved for

patients with potential or established
organ failure and must therefore provide
the facilities for the diagnosis,
prevention, and treatment of multiple
organ failure.
High-Dependency Unit (HDU): Offers
standard of care intermediate between
that available on the general ward and
that in the ICU. For patients at risk for
developing organ failure.
Progressive Care Unit: Provide a
stepdown facility for patients being
discharged from ICU.
Outreach Care: Provide critical care
advice and skills to any patient
throughout the hospital. Provide support
to a patient either returning from critical
care unit to general ward or support
patients on general ward who are
showing signs of deterioration and who
may need to move to critical care unit.

Critical Care Nursing

Critical Care Nursing: Specialty within
nursing which deals specifically with
human responses to life threatening
illness.

Patients experience with critical

illness
Familys experience with critical
illness
Impact of critical care
environment on patient

Perception of Acute Illness

(About ICU admission)

ICU Nurse: ICU is a place where

fragile lives are vigilantly
scrutinized, cared for, and
preserved.
Patient & Family: Sign of
impending death because of their
own or others experiences

Criteria for Admission in the ICU

Categories of organ system monitoring
and support
Advanced respiratory support
a. Mechanical ventilator support
b. Possibility of a sudden,
precipitous deterioration in
respiratory function requiring
immediate ET intubation and
mechanical ventilation.
Basic respiratory monitoring and
support
a. Need for more than 50% oxygen
b. Possibility of progressive
deterioration to needing
advanced respiratory support
c. Need for physiotherapy to clear
secretions at least two hourly
d. Patients recently extubated after
prolonged intubation and
mechanical ventilation.
e. Patients who are intubated to
protect the airway but require no
ventilatory support and who are
otherwise stable.
Circulatory support

Elec II: Acute/Critical Care Nursing

a. Need for vasoactive drugs to
support arterial pressure or
cardiac output
b. Support for circulatory instability
due to hypovolemia from any
cause which is unresponsive to
modest volume replacement
c. Patients resuscitated after cardiac
arrest where intensive or high
dependency care is considered
clinically appropriate
d. Intra-aortic balloon pumping
Neurological monitoring and
support
a. Central nervous system
depression from whatever cause,
sufficient to prejudice the airway
and proective reflexes
b. Invasive neurological monitoring
Renal support
a. Need for acute renal replacement
therapy
Factors to be considered when
assessing suitability for admission
to intensive care: the decision to
admit a patient to an intensive
care unit should be based on the
concept of potential benefit
a. Diagnosis
b. Severity of illness
c. Age
d. Coexisting disease
e. Physiological reserve
f. Prognosis
g. Availability of suitable treatment
h. Response to treatment to date
i. Recent cardiopulmonary arrest
j. Anticipated quality of life
k. The patients wishes

Basic monitoring requirements for

seriously ill patients:
1.
2.
3.
4.
5.
6.
7.

Standard Assessment of Critically Ill

Immediate priority
Preserve life
Prevent, reverse or minimize
damage to vital organs
Achieved by optimizing
cardiovascular and respiratory
function to maximize oxygen to
tissues

Standard assessment of Critically Ill

A. Pre arrival assessment
B. Admission quick check
C. Comprehensive admission
assessment
A. Pre arrival assessment: Begins
with the moment information is
received about upcoming
admission of the patient. Paints
initial picture of patient & allows
critical care nurse to begin
anticipating patients physiologic
and psychological needs
Pre arrival Assessment:
-

Criteria for calling intensive care staff to

adult patients:
a. Threatened airway
b. All respiratory arrests
c. Respiratory rate 40 or 8
breaths/minute
d. Oxygen saturation <90% on 50%
oxygen
e. All cardiac arrests
f. Pulse rate <40 or >140
beats/minute
g. Systolic BP<90mmHg
h. Sudden fall in level of
consciousness (fall in GCS >2
points)
i. Repeated or prolonged seizures
j. Rising arterial carbon dioxide
tension with respiratory acidosis
k. Any patient giving cause for
concern

Heart rate
Blood pressure
Respiratory rate
Pulse oximetry
Hourly urine output
Temperature
Blood gases

Abbreviated report on patient

Age, gender, chief complaint,
diagnosis, pertinent history,
physiologic status, invasive
devices, laboratory tests
Complete room set-up verification
of proper equipment functioning

Equipment for standard ICU room set-up

-

Bedside ECG and invasive

pressure monitor with appropriate
cables
ECG electrodes
BP cuff
Pulse oximetry
Suction gauge and canister
Suction cathers
Bag valve mask device
Oxygen and oxygen delivery
device
IV poles and infusion pumps
Bedside supply cart
Admission kit

Elec II: Acute/Critical Care Nursing

-

Admission and critical care

documentation forms

Patient is connected to
appropriate monitoring and
support equipment, and critical
medications are administered

Admission Quick Check Assessment

Prearrival Assessment
The charge nurse notifies Sue
that she will be receiving a 26-year old
man from the ER who was involved in
a serious car accident. The ED nurse
caring for the patient has called to
give Sue a report. The patient suffered
a closed head injury and chest trauma
with collapsed left lung. The patient
was intubated and placed in a
mechanical ventilator. IV access had
been obtained, and a left chest tube
had been inserted. After obtaining a
computed tomographic (CT) scan of
the head, the patient will be
transferred to the ICU. Sue questions
the ED nurse whether the patient has
been agitated, had a foley catheter
placed, and whether family had been
notified of the accident.
Sue goes to check the
patients room prior to admission and
begins to do a mental check of what
will be needed. The patient is
intubated so Ill connect the AMBU bag
to the oxygen source, check for
suction catheters, and make sure that
suction systems are working. The
pulse oximetry and the ventilator are
ready to go. I have an extra suction
gauge to connect the chest tube
system. Ill also turn in the ECG
monitor and have the ECG electrodes
ready to apply. The arterial line flush
system and transducer are also ready
AdmissionThe
Quick
Check
to B.
be connected.
IV infusion
devices
are
set
up.
This
patient
has an
Assessment
altered
LOC,
which
means
frequent
- Obtained immediately after
neuro checks and potential insertion of

arrival
Quick overview of the adequacy
of ventilation and perfusion to
ensure early intervention for any
life threatening situation

Admission Quick Check

-

Focus is on the exploration of

chief complaint and obtaining
essential diagnostic tests to
supplement physical assessment
findings
Seriousness of the problem is
determined

Appearance (consciousness)
Airway
Breathing
Circulation and cerebral
perfusion, chief complaints
Drugs
Equipment

Admission Quick Check

-

General Appearance
(Consciousness)
Behavior
Airway
Patency
Having the patient speak

Airway
-

Position of the artificial airway

Breathing
-

Quantity and quality of

respirations
Rate
Depth
Pattern
Symmetry
Effort
Use of accessory muscles
Breath sounds
Presence of spontaneous
breathing
Wheezes
Crackles
Rhonchi
Stridor
Pleural friction rub
Presence of spontaneous
breathing

Chief Complaint
-

Focuses on primary body stem

involved and the extent of
associated symptoms

Circulation & Cerebral Perfusion

-

Palpating a pulse
ECG viewing (HR, rhythm, ectopy)
BP and temperature
Peripheral perfusion and capillary
refill
Skin color, temperature, moisture
Presence of bleeding
Level of consciousness,
responsiveness

Elec II: Acute/Critical Care Nursing

Circulation and Cerebral Perfusion
-

IV access initiated
Ongoing IV infusions checked
Verify correct infusion of the
desired dosage and rate

Chief Complaint
-

Primary body system

Associated symptoms

Drugs and Diagnostic tests

-

Drugs prior to admission

(prescribed, OTC, illicit)
Current medications
Review of diagnostic test results

Common diagnostic tests obtained

during Admission Quick Check
Assessment
1. Serum electrolytes
2. Glucose
3. Complete blood count with
platelets
4. Coagulation studies
5. Arterial blood gases
6. Chest x-ray
7. ECG

Evidence-based practice: Family needs

assessment:
Quick Assessment
-

Offer realistic hope

Give honest answers and
information
Give reassurance

Comprehensive Assessment
-

Use open-ended communication and

assess their communication style
Assess family members level of
anxiety
Assess perceptions of the situation
(knowledge, comprehension,
expectations of staff, expected
outcome)
Assess family roles and dynamics
(cultural and religious practices,
values, spokesperson)
- Assess coping mechanisms and
resources (what do they use, social
network and support)
Equipment

Evaluate all vascular drainage

tubes for location and patency,
and connect them to appropriate
monitoring or suction devices
Note color, consistency, and odor
of drainage secretions
Verify appropriate functioning of
all equipment attached and label
as appropriate

Allergies
Comprehensive Admission Assessment
-

Past medical history

Social history
Psychosocial assessment
Spirituality
Review of system
Physical assessment

Initial treatment in ICU

-

In critical illness, the need to

support the patients vital
functions may, at least initially,
take priority over establishing a
precise diagnosis

Initial treatment
-

HR
BP
RR
Temperature
Hourly UO
Pulse oximetry
ABG

Assessment and Treatment (by body

system)
-

Respiratory system

History
Dyspnea
Chest pain
Sputum production
Cough

Health History
-

Inspection
Cyanosis
Breathing
Increase AP diameter of chest
Chest deformities and scars
Patients posture
Position of the trachea
RR
Depth of respiration

Inspection
Duration of inspiration vs.
duration of expiration
o Observation of general
chest expansion
Palpation
Tactile fremitus
Assess subcutaneous emphysema
PERCussion
Assess for dullness and
hyperresonance
o

Elec II: Acute/Critical Care Nursing

Summary of Comprehensive Admission

Assessment Requirements
Suggested Questions for Review of Past History
Categorized by System:

Past Medical History

Nervous

1.
2.

3.
4.
5.
6.

Have you ever had a seizure?

Have you ever fainted, blacked out, or had
delirium tremens (DT)?
Do you ever have numbness, tingling, or
weakness in any part of your body?
Do you have any difficulty with your hearing,
vision or speech?
Has your daily activity level changed due to
your present condition?
Do you require any assistive devices such as
canes?

Cardiovascular
1.
2.
3.
4.
5.

Have you experienced any heart problems or

diseases such as heart attacks or strokes?
Do you have any problems with extreme
fatigue?
Do you have an irregular heart rhythm?
Do you have high blood pressure?
Do you have a pacemaker or an implanted
defibrillator?

Respiratory
1.
2.
3.
4.

Do you ever experience shortness of breath?

Do you have a persistent cough? Is it
productive?
Have you had any exposure to environmental
agents that might affect the lungs?
Do you have sleep apnea?

Renal
1.
2.
3.

Have you had any change in frequency of

urination?
Do you have any burning, pain, discharge, or
difficulty when you urinate?
Have you had blood in your urine?

Gastrointestinal
1.
2.
3.
4.

5.
6.

Has there been any recent weight loss or gain?

Have you had any change in appetite?
Do you have any problems with nausea or
vomiting?
How often do you have a bowel movement and
has there been a change in normal pattern? Do
you have blood in your stools?
Do you have dentures?
Do you have any food allergies?

Integumentary
1.

Do you have any problems with your skin?

Endocrine
1.

Medical conditions, surgical

procedures
Psychiatric/emotional problems
Hospitalizations
Medications (prescription, OTC,
illicit drugs) and time of last
medication dose
Allergies
Review of body systems

Social History
-

Age, gender
Ethnic origin
Height, weight
Highest educational level
completed
Occupation
Marital status
Primary family members/significant
others
Religious affiliation
Advance directive and durable
power of attorney for health care
Substance abuse (alcohol, drugs,
caffeine, tobacco)
Domestic abuse or vulnerable adult
screen

Psychosocial Assessment
-

General communication
Coping styles
Anxiety and stress
Expectations of critical care unit
Current stresses
Family needs

Spirituality
-

Faith/spiritual preference
Healing practices

Physical assessment
-

Nervous system
Cardiovascular system
Respiratory system
Renal system
Gastrointestinal system
Endocrine, hematologic, and
immune systems
Integumentary system

Do you have any problems with bleeding?

Hematologic
Do you have any problems with chronic
infections?
Immunologic
Have you recently been exposed to a
contagious illness?
Psychosocial
Do you have any physical conditions which
make communication difficult (hearing loss,
visual disturbances, language barriers, etc)?

3. Avoid medications that disturb sleep

patterns
4. Mimic patients usual bedtime routine as
much as possible
5. Minimize environmental impact on sleep as
much as possible
6. utilize complementary and alternative
therapies to promote sleep as appropriate

Elec II: Acute/Critical Care Nursing

Peripheral Pulse Rating Scale
0 = Absent pulse
Identification of Symptom Characteristics
Characteristic

Sample Questions

Onset - how and under what

circumstances did it begin? Was the
onset sudden or gradual? Did it progress?
Location where is it? Does it stay in the
same place or does it radiate or move
around?

+1 = palpable but thread; easily

obliterated with light pressure
+2 = Normal; cannot obliterate
with light pressure
+3 = Full
+4 = Full and bounding

Frequency- how often does it occur?

Quality it is dull, sharp, burning,
throbbing, etc?
Intensity- rank pain on a scale (numeric,
word description, FACES, FLACC)
Quantity- how long does it last?
Setting- what are you doing when it
happens?

Auscultation
-

Vesicular
Bronchovesicular
Bronchial
Tracheal
Egophony
Whispered pectoriloquy

Associated Findings- are there other signs

and symptoms that occur when this
happens?

Adventitious breath sounds

Aggravating and alleviating factors- what

things make it worse? What things make
it better?

Respiratory Support: All seriously ill

patients without pre existing lung
disease should receive supplementary
oxygen at sufficient concentration to
maintain arterial oxygen tension
60mmHg or oxygen saturation of at
least 90%

Edema Rating Scale

Following the application and
removal of firm digital pressure
against the tissue, the edema is
evaluated for one of the following
responses:
0 = no depression in tissue
+1 = small depression in tissue,
disappearing in < 1 second
+2 = depression in tissue
disappears in <1-2 seconds
+3 = depression in tissue
disappears in <2-3 seconds

Auscultation pattern

The results of blood gas analysis alone

is rarely sufficient to determine the
need for mechanical ventilation. Several
other factors have to be taken into
consideration.
Factors to consider for the need of
mechanical ventilation:
a. Degree of respiratory work
b. Likely normal blood gas tensions
for that patient
c. Likely course of disease
d. Adequacy of circulation

+4 = depression in tissue
disappears in > or = 4seconds

Evidence-based practice - Sleep

promotion in Critical Care
1.

2.

Assess
patients
usual
sleeping
patterns
Minimize effects of underlying disease
process as much as possible (eg
reduce
fever,
eliminate
pain,
minimize metabolic disturbances)

Elec II: Acute/Critical Care Nursing

Endocrine, hematologic & immunologic

-

Fluid balance, electrolyte and glucose

values, CBC and coagulation values;
temperature; WBC with differential
count

Integumentary
-

Color and temperature of skin;

intactness of skin; areas of redness

Pain/discomfort
-

Assessed in each system; response to

interventions

Psychosocial
-

Mental status and behavioural

responses; reaction to critical illness
experience (eg stress; anxiety,
coping, mood); presence of cognitive
impairments (dementia; delirium);
Ongoing Assessment Template
depression or demoralization; family
functioning and needs; ability to
Body System
Assessment Parameters
communicate needs and participate
in care; sleep patterns
Nervous
Isolation Categories and Related
Infection
Examples
LOC; Pupils; Motor strength of
Isolation Categories
1.
2.
3.

4.

Factors contributing to Sleep Disturbances in

Critical Care
1.
-

2.
3.
-

Illness
Metabolic changed
Underlying diseases (eg cardiovascular
disease, chronic obstructive pulmonary
disease (COPD)
Pain
Anxiety, dear
Delirium
Medications
Beta-blockers
Bronchodilators
Benzodiazepines
Narcotics
Environment
Noise
Staff conversations
Television/radio
Equipment alarms
Frequent care interruptions
Lightning
Lack of usual bedtime routine
Room temperatrure

Unfomfortable sleep surface

extremities
Infection examples
when
used
Cardiovascular

Standard precautions used

care
- with
Blood
pressure; heart rate and
of all patients
rhythm; heart sounds; capillary refill;
Airborne precautions tuberculosis,
peripheral pulses; patency of IVs;
measles (rubeola), varicella verification of IV solutions and
Droplet precautions Neisseria
medications;
hemodynamic
meningiditis, Haemophilus influenza,
pressures and waveforms; cardiac
pertussis, mumps
output data
Contact precautions- Vancomycinresistant enterococcusRespiratory
(VRE),
Methicillin-resistant Staphylococcus
- difficile,
Respiratory rate and rhythm; breath
aureus (MRSA), Clostridium
scabies, impetigo, respiratory sounds; color and amount of
secretions; non-invasive technology
syncytial virus (RSV)
information (eg pulse oximetry; endtidal CO2); mechanical ventilator
parameters; arterial and venous blood
gases
Renal
-

Intake and output; color and amount

of urinary output; BUN/creatinine
values

Gastrointestinal

Mechanical

bowel sounds; contour of abdomen;

position of drainage tubes; color &
amountof secretions; bilirubin &
Ventilation
albumin values

ET to VC TV 500 FiO2 40% BUR 14 PEEP

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Elec II: Acute/Critical Care Nursing

TT to PCV Pinsp 8 FiO2 .6 f18 PEEP 7

Negative Pressure Ventilators

Mechanical Ventilation: Delivery of air

into the patient by positive pressure

Iron Lung: Patients body encased in iron

cylinder and negative pressure is
generated to enlarge the thoracic cage

Manual resuscitation: Nurses first line

of defense for acute respiratory failure
Bag-valve mask
Must be connected to an oxygen source
to deliver oxygen 0.74 to 1.00
concentrations
The force of squeezing the bag
determines the tidal volume delivered to
the patient
The number of hand squeezes per
minute determines the rate
The force and rate that the bag is
squeezed determined the peak flow
Nursing Responsibilities:
-

Assess the spontaneous breath of

the patient
Observe the patients chest to
determine whether the bag is
performing properly
Assess for gastric distention
The ease or resistance
encountered can indicate lung
compliance
The nurse must allow time for
complete exhalation between
breaths to prevent auto-PEEP
Make sure that the bag is
connected to an oxygen source

Mechanical Ventilators
Goals of Mechanical Ventilation:
-

To maintain alveolar ventilation

appropriate for the patients
metabolic needs
To correct hypoxemia
To maximize oxygen transport

Clinical Goals of Mechanical Ventilation

-

Reversal of hypoxemia
Reversal of acute respiratory
acidosis
Relief of respiratory distress
Prevention or reversal of
atelectasis
Resting of ventilator muscles

Clinical Goals of mechanical ventilation

-

Decrease in systemic or
myocardial oxygen consumption
Reduction of ICP
Stabilization of chest wall

Iron Lung
Positive Pressure Ventilators
-

Pressure-cycled
Time-cycled
Volume-cycled

Pressure-Cycled
-

Once preset pressure is reached,

inspiration is terminated
For patient with compliant lungs
Can be used as weaning tool

Time-Cycled
-

Once preset time is finished,

inspiration is terminated
Expiratory time is determined by
the inspiratory time and rate
Normal I:E ratio
1:2

Volume-cycled
-

Once a designated volume of air

is delivered to the patient,
inspiration is terminated
Advantage: can deliver consistent
tidal volume regardless of patient
lung compliance

High Frequency Ventilator

Uses small tidal volume (1 to 3 mL/kg)
at frequencies greater than 100/min to
achieve lower peak pressures, lowering
the risk of barotrauma
Ventilatory Modes
o
o
o
o
o
o
o

Assist Control (A/C)

SIMV
PSV
PCV
IRV
CPAP
NIPPV

Assist Control (A/C): rate & tidal volume

-

Basic rate is set

If patient breathes faster, the
ventilator will be triggered to
assist the patient
Preset tidal volume is achieved at
each breath
Used as initial mode of ventilation
Disadvantages: air trapping,
hyperventilation

Elec II: Acute/Critical Care Nursing

Synchronized Intermittent Mandatory
Ventilation (SIMV)
-

Rate and volume are preset

Any breaths taken above the set
rate are spontaneous breaths
Spontaneous tidal volume vary
from the machines set tidal
volume

Synchronized Intermittent Mandatory

Ventilation (SIMV)
-

Allows spontaneous breaths

Used as an initial mode of
ventilation
Disadvantage: patient-ventilator
asynchrony is possible

Pressure Support Ventilation

-

Assist spontaneous breathing

efforts of the patient
No set TV and rate
Pressure support 5-10cm H2O

Pressure Support Ventilation

-

Intact respiratory drive in patient

is necessary
Used as weaning mode
Decreases work of breathing,
increases patient comfort
Not to be used in patients with
acute bronchospasm

Inverse Ratio Ventilation

-

Continuous Positive Airway Pressure

(CPAP)
-

Nurse must monitor TV and rate

at least hourly
Monitor for changes in
compliance

Pressure Controlled Ventilation

-

No set tidal volume but with set

inspiratory pressure and rate
Decrease risk of barotrauma
For ARDS
Used to limit airway pressures

Pressure Controlled Ventilation

-

Monitor for barotrauma and

hemodynamic instability
Monitor tidal volume at least
hourly
Possible patient-ventilator
asynchrony

Inverse Ratio Ventilation (IRV)

-

Used in conjunction with PCV

Increases ratio I:E allow for
recruitment of alveoli and
improve oxygenation

Constant positive pressure for

patients who breathe
spontaneously
Used in intubated and nonintubated patients

Continuous Positive Airway Pressure

(CPAP)
-

Some systems, no alarm if

respiratory rate fails
Monitor for increased work of
breathing

Non-invasive Positive Pressure

Ventilation (NIPPV)
-

For nocturnal hypoventilation in

patients with neuromuscular
disease, chest wall deformity,
obstructive slee apnea and COPD

Non-invasive Positive Pressure

Ventilation (NIPPV)
-

Pressure Support Ventilation

-

Requires paralysis
Monitor for auto-PEEP,
barotrauma, hemodynamic
instability

Decreased cost when patients

can be cared for at home, no
need for artificial airway

Non-invasive Positive Pressure

Ventilation (NIPPV)
-

Disadvantage: patient discomfort

discomfort
Claustrophobia
Aspiration risk
Monitor for gastric distention

Ventilator Controls
-

Fraction of inspired oxygen

Tidal volume
Respiratory rate
Pressure limit
PEEP

Fraction of Inspired Oxygen

-

FiO2
Initially patients will be on 60%
Changes in FiO2 is based on ABG,
or to maintain SaO2 >90%
Risk for Oxygen toxicity when
FiO2 is > 60% for 12 to 24 hours

Tidal Volume
-

Volume of air at each breath

10

Elec II: Acute/Critical Care Nursing

-

8-10ml/kg

Respiratory rate
-

Frequency
Number of breaths per minute

Respiratory rate
-

Minute Ventilation = RR x tidal

volume
Determines alveolar ventilation
Increasing the MV decreases
PCO2
Decreasing the MV increases the
PCO2

Pressure Limit
-

Limits the highest pressure

allowed on the ventilator
Once high pressure is reached,
inspiration is terminated
Prevents barotrauma

PEEP
-

Positive end-expiratory pressure

Pressure maintained in lungs at
the end of expiration
Oxygenation improves when PEEP
is used to recruit alveolar units
that are collapsed

PEEP
-

Holds the alveoli open by

maintaining pressure in the
alveoli at the end of expiration

PEEP
-

Complications: decreases blood

return to the heart

Barotrauma
Sensitivity
-

Amount of patient effort needed

to initiate inspiration
Expressed by negative inspiratory
effort

Sensitivity
-

Increasing the sensitivity,

decreases the amount of work the
patient must do to initiate a
breath
Decreasing the sensitivity,
increases the amount of negative
pressure that the patient needs

Alarms
-

Warn the care provider of the

developing problems

Low volume alarm

Ventilator leaks
Low pressure alarm
Disconnection from the ventilator

Alarms
-

High pressure
Decreased compliance
Kinks in the tubing
Patient biting the tube
Secretions
Patient-ventilator asynchrony

Humidification and Thermoregulation

-

Mechanical ventilation bypasses

the upper airway
All ventilator circuits must have
humidifier with temperature
control
Temperature of air is about the
same as body temperature
Moisture must be drained from
the vent circuits
Humidifier increases risk of
bacterial contamination, regular
vent circuit change as per policy

Complications of mechanical support

-

Aspiration
Ventilator malfunction
Barotrauma
Decreased cardiac output
Water imbalance
Immobility
GI problems

Collaborative Care for patient on

Mechanical Ventilation
Outcomes: Oxygenation/Ventilation
-

Patent Airway is maintained

Lung is clear on auscultation
ABG are within normal limits

Oxygenation/Ventilation
-

Interventions: Auscultate breath

sounds q2-q4h and PRN
Suction only when rhonchi is
present or secretions are visible
in ET tube
Hyperoxygenate and
hyperventilate patient before and
after sunctioning
Turn to sides every 2 hours
Mobilize to a chair or standing
position whenever possible
Monitor pulse oximetry and ABG

Circulation and Perfusion

11

Elec II: Acute/Critical Care Nursing

-

BP, CO, CVP and pulmonary

artery pressure remains stable
related to mechanical ventilation
Interventions: assess
hemodynamic effects of
mechanical ventilation
Monitor ECG for dysrhythmias
Administer intravascular volume
as ordered

Comfort and Pain Control

-

Fluids and electrolytes

-

Intake and output measurements

are balanced
Interventions: monitor hydration
status to decrease viscosity of
secretions
Assess urine specific gravity and
serum osmolality

Mobility and Safety

-

There is no evidence of muscle

wasting
Intervention: promote standing at
the bedside, sitting up in a chair,
ambulating with assistance as
soon as possible

ET tube will remain proper

position
Interventions: securely stabilize
the ET tube
Note and record the cm line of
ET at lip level
Use restraints as appropriate
Evaluate ET tube position on
chest x-ray
Keep emergency airway
equipment and BVM readily
available, check each shift
Proper inflation of T tube cuffs is
maintained
Interventions: inflate cuff using
minimal leak technique, or
pressure < 25mmHg
Monitor cuff inflation q2-q4H
Protect pilot balloon from damage

Skin Integrity
-

There is no evidence of skin

breakdown
Interventions: turn to side q2h
Remove protective devices from
wrist and monitor skin as per
policy

Nutrition
-

Nutritional intake meets

metabolic need
Interventions: consult dietician

Patient will not complain of pain

related to intubation and
mechanical ventilation
Interventions: analgesia,
meticulous mouth care, sedation
as indicated

Comfort and Pain Control

-

Prevent pulling and jarring of the

ventilator and ET tube

Psychosocial
-

Patient assumes some control

and participates in care
Patient communicates with health
care providers and visitors

Interventions
-

Mobility and Safety

-

Provide early nutritional support

Take daily weights
Avoid high carbohydrate intake

Encourage patient to move in bed

independently
Establish a daily schedule for
bath, out-of-bed treatment that
allows participation
Provide a means to write notes
and use visual tools to facilitate
communication

Teaching/Discharge Planning
-

Patient is cooperative and

indicates understanding of need
for mechanical ventilation
Interventions
Provide explanations to
patients/significant others
regarding:
Rationale of use of ventilators
Procedures such as suctioning
Plan for weaning and extubation

Interventions
-

Teach visitors to assist with ROM

exercises

PEEP
Medications for Ventilated Patients
Sedative
-

Midazolam, Propofol

Paralytic
-

Atracium, rocuronium,
succinylcholine

Opioids

12

Elec II: Acute/Critical Care Nursing

-

Morphine, fentanyl

Renal System
Renal support
-

Renal failure is a common

complication of acute illness or
trauma and the need for renal
replacement therapy may be a
factor when considering referral
to ICU

Blood Urea Nitrogen & Creatinine

-

Urine volume
Fluid balance
Renal concentrating power
Acid-base balance
Rate of rise of BUN, creatinine,
and potassium concentrations

Indications for considering renal

replacement therapy
-

Oliguria (<0.5mL/kg/h)
Life threatening hyperkalemia
(>6mmol/l) resistant to drug
treatment
Rising plasma concentrations of
urea or creatinine, or both
Severe metabolic acidosis
Symptoms related to uremia
(pericarditis, encephalopathy)

Indications for considering renal

replacement therapy
-

Creatinine: by-product of normal

muscle metabolism
Primarily excreted in the urine as
a result of glomerular filtration
Amount of creatinine excreted is
directly related to muscle mass

Serum
Urine
Reference interval varies with
race, ethnicity and gender

Blood Urea Nitrogen

-

Urea production occurs primarily

in the liver
Small percentage in blood
Excretion in sweat and urine
NV 3-20mg/dL
Increased urea production can
result from:
increased tissue breakdown
increased protein intake
febrile illnesses
steroids
tetracycline administration

sequelae of neurological
impairment may lead to patient
requiring intensive care
loss of consciousness may lead to
obstruction of airways, loss of
protective airway reflexes, and
disordered ventilation that
requires intubation or
tracheostomy and mechanical
ventilation

Neurological considerations in ICU

referral
-

airway obstruction
absent gag or cough reflex
measurement of ICP and cerebral
perfusion pressure
raised ICP requiring treatment
prolonged or recurrent seizures
which are resistant to
conventional anticonvulsants
hypoxemia
hypercapnia or hypocapnia

Nervous System
-

Creatinine
-

varies inversely with GFR

Neurological System

The need for renal replacement therapy

is determined by:
-

reabsorption of blood from the

intestines

LOC: single most important

indicator of cerebral functioning
Observation of patients
behaviour, appearance, and
ability to communicate
First step in assessing level of
consciousness:
o Auditory stimuli
Can you open your eyes?
o Tactile stimuli
Gentle touch or shake

Describe what stimulus is used: (order

of stimuli)
1. Call patient by name
2. Call name louder
3. Combine calling name with light
touch
4. Combine calling name with
vigorous touch (shake and
shout)
5. Create pain
Grading Responsiveness
-

Alert: Normal
Awake: may sleep more than
usual or be somewhat confused

13

Elec II: Acute/Critical Care Nursing

on first awakening, but fully

oriented when aroused.
Lethargic: drowsy but follows
simple commands when
stimulated
Stuporous: very hard to arouse;
inconsistently may follow simple
commands or speak single words
or short phrases
Semi-comatose: movements are
purposeful when stimulated; does
not follow commands or speak
coherently
Comatose: may respond with
reflexive posturing when
stimulated or may have no
response to any stimulus

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

Muscle strength
-

Pain stimulus

Central stimulus

Squeezing trapezius muscle

Supraorbital pressure
Sternal rub

Peripheral stimulus
-

Nail bed pressure

Glasgow Coma Scale

1. Eye opening
2. Verbal response
3. Motor response
Level of consciousness
2 components:
a. Arousal
b. Awareness
Arousal
-

State of wakefulness
Reflects function of reticular
activating system and brainstem

Content and quality of

interactions
Reflects functioning of the
cerebral cortex

Decorticate posturing (flex)

-

Damage in the cerebral

hemispheres or thalamus

Decerebrate posturing (extend)

-

Damage to the midbrain or pons

Decerebrate or decorticate

Neurological history
Recent trauma that could affect
the nervous system
Recent infections (sinusitis or ear
infections)
Feeling of dizziness, loss of
balance, black-out spells
Clumsiness or weakness of
extremities

Neurological history
-

Sensory distortions (numbness,

tingling)
Tobacco, alcohol, and drug use
Prescription and OTC drugs

AEIOU tips (causes of altered mental

status)
1.
2.
3.
4.
5.
6.
7.
8.
9.

Alcohol
Epilepsy
Insulin
Overdose/oxygenation
Underdose/uremia
Trauma
Infection
Psychosis
Stroke/shock

Circulatory Support
-

Awareness
-

Pupils
Shape
Size and reaction
Symmetry
Corneal reflex
Cranial nerves V and VII
Protective reflex
Brainstem function
Gag reflex and ability to swallow
Cough reflex controlled by cranial
nerves IX and X

An adequate arterial pressure is

essential for perfusion of major
organs and glomerular filtration,
particularly in elderly or
hypertensive patients, and for
sustaining flow through any areas
of critical narrowing in the
coronary and cerebral vessels

Circulatory support
-

Shock represents a failure of

tissue perfusion
It is primarily a failure of blood
flow and not of BP

Signs suggestive of shock:

1. Tachycardia

14

Elec II: Acute/Critical Care Nursing

2. Confusion or diminished
conscious level
3. Poor peripheral perfusion (cool,
cyanosed extremities, poor
capillary refill and peripheral
pulses)
4. Poor urine output (?ml/hour)
5. Metabolic acidosis
6. Increased blood lactate
concentration
Cardiovascular system
-

Assessment of central and

peripheral perfusions
BP, heart rate and rhythm
ECG
T-wave abnormalities
ST segment changes
PR, QRS, and QT interval

Cardiovascular system
-

Pulse pressure
Color and temperature of skin
Nail color and capillary refill

ECG waveform
P wave: atrial depolarization
QRS complex: ventricular repolarization
T wave: ventricular repolarization
U wave: repolarization of the papillary
muscles or Purkinje fibers
PR interval
-

Amplitude and quality

Check pulse simultaneously and
compare
If pulse is difficult to palpate, use
Doppler ultrasound

Peripheral pulse
-

Doppler ultrasound

Pulse deficit
-

Difference in count between

heartbeat
(apical beat) and peripheral pulse
This occurs even as the heart is
contracting, the pulse is not
reaching the periphery

Cardiac History
-

Chest pain
Dyspnea
Edema of feet/ankles
Palpitations/syncope
Cough and hemoptysis
Nocturia
Cyanosis
Intermittent claudication

Electrical activity of the heart

Depolarization
Repolarization
Not mechanical function of heart
Contraction

Measure of time between start of

Q wave and end of T wave
Represents electrical
depolarization and repolarization
of left and right ventricles

Paroxysmal Supraventricular
Tachycardia (PSVT)
Defibrillation and Cardioversion
-

Electrical countershock therapy

AHA five-part chain of survival

concept
-

Immediate recognition &

activation of EMS
Early CPR
Rapid defibrillation
Effective ALS
Integrated post-cardiac arrest
care

Monophasic defibrillators
-

Max 360 Joules

Biphasic Defibrillators
-

Max 200 Joules

Safety
-

Cardiac dysrhythmias
Electrocardiogram

Time the electrical impulse takes

to travel from sinus node to AV
node
0.12 sec to 0.20 sec
Good estimate of AV node
function
QT interval

QT Interval

Peripheral Pulse
-

Relaxation

Make sure no one is touching the

patient, the bed, or any
conductive material that is
attached to the patient
all clear

Defibrillation
-

Pulseless ventricular tachycardia

Ventricular fibrillation

15

Elec II: Acute/Critical Care Nursing

-

Cardiac arrest due to or resulting

in VF

Cardioversion
-

Useful in:
Unstable VT with pulse
Supraventricular tachycardia
Atrial flutter
Atrial fibrillation
When patient becomes unstable
or does not convert to normal
rhythm with pharmacological
agents

Cardioversion
-

Synchronized with the hearts

activity
SYNC button must be on
Detects the patients R wave and
delivers shock during ventricular
depolarization

Cardioversion
-

After conversion to sinus rhythm,

antiarrhythmic therapy should be
initiated

Cardioversion
-

NPO for 6-8 hours

Withhold digitalis for 24 hours
before cardioversion
Turn ON the synchronizer mode
button.
Sedate the patient and maintain
adequate airway.
Reconfirm synchronization
markers on the R waves of the
monitor cardiac pacemaker
Electronic device that delivers
direct electrical stimulation to
myocardium to depolarize
Initiates and maintains HR when
natural pacemaker is unable
Cardiac pacing is evidenced by
presence of spike or pacing
artifacts

Pacemakers
-

Spike or pacing artefact

Central venous pressure
monitoring
Pressure in right atrium
Provides information about:
o Intravascular blood volume
o Right ventricular end
diastolic volume
o Right ventricular function

CVP catheter

Inserted under sterile conditions

Antecubital, jugular, femoral, or
subclavian access route, threaded
into position in the vena cava
close into the right atrium

CVP catheter
-

Central venous pressure

measurement
Water manometer
Pressure transducer

Pressure transducer
-

Complications of CVP
Infection
Thrombosis
Air embolism

Nursing considerations (CVP)

-

Normal values 5-8cm H2O

0-6mmHg
The trend of the values is most
significant than one single CVP
measurement
As related to the patients CV
dysfunction and the response to
intervention

Nursing considerations (CVP)

-

CVP is always interpreted in

conjunction with other clinical
observations (auscultation of
breath sound, HR, RR, ECG, neck
vein distention and urine output)

Pulmonary Artery Pressure Monitoring

-

Flow directed, balloon tipped

catheter
Cardiac output
RA, RV, and PA pressures
PAOP

Swan-Ganz Catheter
Swan-Ganz Complications
-

Infection
Pneumothorax
Ventricular dysrhythmias
Pulmonary artery rupture
Length of insertion should be
noted

Swan-Ganz Catheter responsibilities

-

Normal values = 8-12mmHg

Measurement of all hemodynamic
pressures is most accurate when
obtained at end expiration of the
respiratory cycle

Swan-Ganz Catheter

16

Elec II: Acute/Critical Care Nursing

-

Hemodynamic monitoring
Cardiac output
Stroke volume
Mean arterial pressure
Systemic vascular resistance
Pulmonary vascular resistance

Cardiac output
-

Volume of blood ejected from the

heart per minute
Stroke volume x HR
4-8 liters/minute

Increased Pulmonary vascular

resistance
-

Determined by: volume of blood

in ventricles end of diastole
Impedance to from the heart
Contractile ability of the heart

Stoke volume
-

Volume of blood ejected by the

ventricles with each ventricular
contraction
Normal range: 60-100ml/beat

Stroke volume
-

Factors affecting SV: preload,

afterload, inherent myocardial
contractility

Preload
-

Amount of stretch of the cardiac

muscle fiber just before systole
Amount of stretch is proportional
to the volume of blood in the
chambers just before systole or at
the end of diastole

Preload
-

Related to Starlings law of the

heart
Force of myocardial contraction is
determined by the length of the
muscle fibers

Afterload
-

Force or pressure against which a

cardiac chamber must eject nlood
during systole
Determining factor is vascular
resistance in systemic or
pulmonary vessels

Pulmonary vascular resistance (PVR)

-

Resistance in the pulmonary

vascular bed against which the
right ventricle must eject blood
Afterload of right ventricle
80x(MPAP-PAWP)/CO

Pulmonary hypertension
Pulmonary edema

Systemic Vascular Resistance

-

Cardiac output
-

155-255 dynes.sec/cm5

Left ventricular afterload

Resistance of LV to pump blood
against the aorta or systemic
vessels
80x(MAP-RAP)/CO
800-1200 dynes.sec/cm5

Increased systemic vascular resistance

-

Vasoconstriction
Hypothermia

Decreased systemic vascular resistance

-

Vasodilation
Hyperthermia
Sepsis

Contractility
-

Affected by: adenosine

monophosphate, intracellular
calcium, ATP

Vasoactive Agents
Evidence-based practice: Bedside Cardiac
Monitoring for Arrhythmia Detection
Electrode Application
o Make sure skin is clean and dry before
applying monitoring

Evidence-based practice: Family Interventions

Planning
o Determine what the family sees as
priority needs
Interventions
o Determine spokesperson and contact
person
o Establish optimum methods to contact
and communicate with family
o Make referrals for support services as
appropriate
o Provide information according to family
needs
o Include family in direct care
o Provide a comfortable environment
Evaluation
o Evaluate achievement of meeting
family needs through multiple
methods (eg feedback, satisfaction
surveys, care conferences, follow-up
after discharge

Evidence-based practice: Family Visitation in

Critical Care

Establish ways for families to have

access to the patient (eg open

17

Elec II: Acute/Critical Care Nursing

visitation, contract visitation, unit

phone numbers)
Ask patient their preferences related to
visiting
Promote access to patients with
consistent unit policies and procedures
with options for individualization
Prepare families for visit
Model interaction with patient
Give information about the patients
condition, equipment and technology
being used
Monitor the response of the patient
and family to visitation

Transport Personnel and Equipment

Requirements
Personnel
o A minimum of two people should
accompany the patient
o One of the accompanying personnel
should be the critical care nurse
assigned to the patient or a specifically
trained critical care transfer nurse.
This critical care nurse should have
completed a competency-based
orientation and meet the prescribed
standards for critical care nurses
o Additional personnel may include a
respiratory therapist, registered nurse,
critical care technician, or physician. A
respiratory therapist should
accompany all patients requiring
mechanical ventilation
Equipment
The following minimal equipment should be
available:
o Cardiac monitor/defibrillator
o Airway management equipment and
resuscitation bag of proper size and fit
for the patient
o Oxygen source of ample volume to
support the patients needs for the
projected time out of the ICU, with an
additional 30 minutes reserve.
o Standard resuscitation drugs:
epinephrine, lidocaine, atropine,
o Blood pressure cuff
(sphygmomanometer) and
stethoscope
o Ample supply of the IV fluids and

continuous drip medications (regulated

by battery-operated infusion pumps)
being administered to the patient
Additional medications to provide the
patients scheduled intermittent
medication doses and to meet
anticipated needs (eg sedation) with
appropriate orders to allow their
administration if a physician is not
present
For patients receiving mechanical
support of ventilation, a device
capable of delivering the same
volume, pressure, and PEEP and an
FiO2 equal to or greater than what the
patient is receiving in the ICU. For
practical reasons, in adults an FiO2 of
1.0 is most feasible during transfer
because this eliminates the need for
an air tank and air-oxygen blender.
During neonatal transfer, FiO2 should
be precisely controlled
Resuscitation cart and suction
equipment need not accompany each
patient being transferred, but such
equipment should be stationed in
areas used by critically ill patients and
be readily available (within 4 minutes)
by a predetermined mechanism for
emergencies that may occur en route

Reference:
Chulay, M., Burns, S. 2010. AACN
Essentials
of Critical Care
Nursing Second
Edition. The
McGraw-Hill Companies, Inc.