Transcript Nursing Care of Patients experiencing Critical Illness

Nursing Care of Patients
experiencing Critical Illness
C. Cummings EdD,RN
Critical Care
• The first “intensive care unit” was set up at
JHH in the early 1900’s for postop
neurosurgical patients.
• PICU at Cook County hospital in Chicago
followed in 1910.
• After WWII, shock units were first formed
• Mechanical ventilation began in the 1950’s
and by 1997 there were 5000 ICU in the US
AACN Critical Care Standards
• Care for acutely and critically ill patients
• Provide them in-depth education, research
and collaboration with members of the health
care team
• Highly trained staff, who are certified on a
variety of technical equipment
• Lower nurse patient relationship
ICU
ICU patient
MIEMS
Golden Hour
• R. Adams Cowley, shock trauma center was the first
in the country in 1969
• Golden Hour
– Treat the patient within 1 hour of injury
– Mortality rate prior to 1970 was 70%, at MIEMS,
it is now 3%
– Full body helial CT within 20 minutes of arrival,
many new technological advances
• Pulse ox, capnography, inline blood gases, etc.
– Developed teams to perform all processes and
were the first with computerized medical records
Shock
• What is shock?
• Is it a disease or a condition?
• When the body can not oxygenate all of the
organs, what does this lead to?
Shock Classifications
• Four functional impairment systems
• Key features of shock are similar
• Organ perfusion r/t MAP (mean arterial
pressure) What organs poorly tolerate
hypoxia??
• Factors that influence the MAP are:
– Total blood volume
– Cardiac output
– Size of the vascular bed
Shock Classifications
• Hypovolemic
– Total body fluid decreased
– Hemorrhage & dehydration
• Cardiogenic
– Pump failure, fluid volume ok
– MI, valvular problems, dyrhythmias, cardiac
arrest, myopathies
Shock Classifications
• Distributive
– Fluid shifted from central vascular space, body
fluid remains normal or increased
– Neural loss of vascular tone, why??
– Chemical loss of vascular tone, why??
• Obstructive
– Cardiac function decreased by non-cardiac factors,
fluid not affected
– Pulmonary hypertension, pneumothorax,
pericarditis, tamponade (what is that?)
What happens with shock?
• Anaerobic cell metabolism
• Main trigger is a decrease in MAP, results from
decreased C.O., decreased blood volume or
expansion of the vascular bed (think of what can
cause this?)
• C.O.= HR x what??
• Drop of just 5-10mm Hg is detected by
baroreceptors in the aortic arch and carotid sinus
Process of Shock
• Baroreceptors send info to the brain, which
stimulates systems to shunt blood into vital
areas: heart, brain, lungs (what systems are
stimulated?)
• Leads to an increase in lactic acid, protein
destroying enzymes and oxygen radicals
• If corrected in 1-2 hours, it may be reversible,
if not, can lead to MODS
Stages of Shock
• Initial
– MAP < 10mm
– Flow to vital organs is
maintained
– Vascular constriction &
increased HR
– C.O. and MAP are
maintained
– Slight increase in HR, RR and
DBP, why DBP and not SBP?
Stages of Shock
 Compensatory
(nonprogressive)
◦ MAP decreases 10-15
mmHg
◦ Kidney and hormones
are activated
◦ RAAS, epi/norepi
release
◦ Acidosis and
hyperkalemia, why??
◦ Can be reversible if
stabilized
Stages of Shock
• Intermediate
(progressive)
– Sustained decrease in
MAP >20mm Hg
– Less vital organs
become anoxic, what
are they?
– Ischemia occurs, can
only tolerate for a
short time
– Life-threatening
– Must correct in 1 hour
Stages of Shock
• Irreversible (refractory)
– Too much cell death and
tissue damage has occurred
– Therapy is not effective,
even if the MAP returns to
normal
MODS- Multi-organ dysfunction
syndrome
Injury
Release toxins into
plasma
MODS/ Death
Cytokines, TNF
Platelet-activating factor
Prostaglandins
leukotrienes
Myocardial depressants
Shock
Kidney
Liver
Lung
Brain
Vasodilation
Leukocyte aggregates
Endothelial destruction
Myocardial depression
Hypovolemic Shock
• Too little circulating blood
volume, MAP decreases, O2
decreases
– What things can cause a low
blood volume?
• How can you prevent
shock?
• List at least 5 ways
Case Study
• A 36-year-old motorcyclist, J.M., is admitted to the ICU after
being hit by a car. His initial injuries are diffuse cerebral
contusions, a left-sided flail chest, a ruptured spleen, a
lacerated liver and a fractured left femur. He has undergone a
laparotomy at which his spleen was removed, his liver
repaired and a corpak feeding tube inserted. His femur has
been internally fixed. During initial resuscitation and surgery
he received 24 units of blood, as well as other fluids and
blood products
JM- 36 years old, married with one child, ETOH
present in system
Case Study
• What type of shock is this patient in? Why?
• What stage of shock is he in?
• What do you think his vital signs may be? How is his
cardiac output?
• What is a flail chest?
• Can there be a complication from receiving a large
volume of blood products?
• Why the corpak tube??
Case Study
• He has decreased C.O.
• What interventions can be
done for this?
• Inadequate tissue perfusion
• Inadequate fluid volume
• Risk for injury
• Name an intervention for
this
• List 2 things to be done for
restoration
• How can you protect him?
Case Study
• Note what changes may be
seen next to each item.
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MAP
Stroke Volume
Pulse Pressure
pH
pCO2
Lactic Acid
Hematocrit
K
Case Study
• It is 4 days postop and J.M.’s leg has begun to
swell around the femur and there is a
decreased pulse and sensation in that leg.
• What could this be?
• What interventions would be done to assess
this?
Case Study
• J.M. returns to surgery for a revision of the IF
and clot removal, it is 8 hours postop and
while doing your assessment, he seems
confused. He can’t remember his name and
his skin is very cool and clammy. His capillary
refill is >10sec and his breathing is rapid and
shallow. He is quickly becoming more
lethargic and his BP is now 76/45.
Case Study
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What do you do???
List 5 emergent interventions
Should his head be up or down?
He has a 20 ga IV in his R hand, is this enough?
What type of fluids may be ordered?
What labs should be done?
Case Study
• The MD orders the
following medications to be
started, you know that each
does what?
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Dopamine
Epinephrine
Norepinephrine
Phenylephrine
Milrinone
Atropine
Dobutamine
Nitroprusside
Case Study
• It is now 1 week later
and JM is improving,
what value would you
look at to assess for
good organ function?
• What types of therapy
may JM need at home?
Cardiogenic Shock
• Heart muscle is unhealthy and the pump is
impaired, when would this occur?
• Besides and MI, what else can cause this?
• Think back to the MODS example, what could
cause damage to cardiac muscle?
Cardiogenic Case Study
• Ed is a 54 year old teacher, who has been
having chest pain for a the past 6 hours. He
came to the ED and was immediately taken to
the cath lab for a PTCA. They found an 80%
occlusion in the RCA and a 90% occlusion in
the LAD. The following is his story
OHS patient
• http://www.youtube.com/watch?v=XfZGNZEd
Ruk&feature=related
Coronary Artery Bypass Surgery
(CABG)
• One of the most common surgeries in the US for older adults,
half are over 65
• Blockage is removed and the patient’s own venous or arterial
blood vessel is used.
• Internal Mammary (IMA), Saphenous Vein (SV) and radial
artery are used
• Vessels are typically occluded >70%
• Ejection Fraction, EF>40%
• 70% remain pain free 5 years post surgery
Open Heart Surgery (OHS)
• Performed not only for CABG, but also for
valve replacement, tumors, cardiogenic shock
requiring revascularization, VAD placement
• What types of things should be discussed with
the patient preoperatively?
Operative Procedure
• Cardiopulmonary
Bypass (CPB) machine
• Cannulate the IVC and
SVC (inferior and
superior vena cava)
• Blood is totally
diverted, cooled,
oxygenated and then
returned
CABG procedure
• Heart is stopped with a
Potassium solution and
then the grafting begins
• Heart is rewarmed and
observed for patency
• Epicardial wires are placed
and attached to an external
pacemaker
• Mediastinal Chest Tubes are
also placed, usually 4
Epicardial Pacemaker & Chest tubes
Postoperative Care
• Patient is on mechanical ventilation until he is
awake, can take breaths sufficient to meet a
set tidal volume and can lift his head off the
bed
• He has epicardial wires, mediastinal tubes,
foley, Central line, may or may not have a
Swan Ganz Catheter, IV fluids and maybe
vasopressor drips
• What kind may these be?
Post operative care
• How would you monitor fluid balance?
• What electrolytes may need to be replaced?
• What IV medications may be given to maintain
his BP?
• What do you think can be done to warm the
patient?
• What if the BP becomes too high?? Why
would this happen?
Rewarming- Bear Hugger
• What do we want the
temp to be?
Swan Ganz Catheter
Hemodynamic monitoring
Use of Invasive Catheters
• Remember:
– Zero line to atmospheric air
– Level it at the phlebostatic
axis: midaxillary, 4th ICS
– Use a pressure bag
Swan Ganz Monitoring
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Why would a Swan be used?
What kind of things can be monitored off of it?
What is a PAWP? What does this monitor?
Why shouldn’t you leave the wedge balloon inflated?
Cardiac Output and SVO2 (systemic venous oxygenation) can
even be monitored by a swan
• http://www.edwards.com/products/pacatheters/thermodiluti
oncatheter.htm
Complications Post CABG
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Fluid & Electrolyte Imbalance
Dysrhythmias- PVC’s common
Hypo/Hypertension- < C.O.
Hypothermia
Bleeding
– Bleeding from chest tubes, if >150ml/hr call MD,
may need to return to surgery
Complications
 Cardiac Tamponadenarrow pulse pressure,
drop in BP and C.O.,
decrease in CT
drainage (around the
heart), JVD, pulsus
paradoxis (BP > 10
mmHg on expiration
than inspiration)
 EMERGENCY
Complications
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Heart failure- failure of the LV to recover
Cardiogenic Shock- pump failure
MI- clot can dislodge or reocclude
Fatal dysrhythmias- ventricular or heart block
Pneumonia- VAP( ventilator associated)
Atelectasis- chest tube complications or pneumonia
CVA
ARF
Infection- medianstinitis- fever 4 days post, redness at incision
line, may reopen
• Stress Ulcer
• Pericardiotomy syndrome- pain in pericardial area, fluid may
remain and may feel like tightness, pain on inspiration, may
need antibiotics and steroids
Cardiogenic Shock and the Intraaortic Balloon
Pump (IABP)
Balloon Pump
• Acts to divert blood back into the coronary
artery on diastole, so that they maintain a
better perfusion and so a better LV filling and
push
• Should increase the BP and C.O.
• Be careful that the balloon does not move or
cause dysrhythmias, has to be timed to the
patient’s rhythm
Open Heart Surgery- Home Care
• What type of teaching should be done for the
patient on discharge?
• Can they return to work? To exercise?
• What types of medication may they be on?
• What should they do if they have chest pain?
Distributive Shock
• Loss of sympathetic tone, blood vessel
dilation, pooling of blood in capillary beds and
increased vessel permeability
• There are two types of Shock
– Neural and Chemical
– What may be a cause of each type?
Anaphylaxis and Sepsis
• Anaphylaxis is the result of type 1 allergic reactions, antigenantibody reaction, IgE, basophils and mast cells
– Can lead to decreased cardiac contraction, dysrhythmias, bronchial
edema and hypoxia death
• Sepsis is caused by toxins released by organisms invade the
body and cause a whole-body inflammatory process or SIRS
(systemic inflammatory response syndrome)
Sepsis
• SIRS leads to DIC or (disseminated
intravascular coagulation)
– Small clots form as the result of toxins and
inflammation in order to stop the infectious
process, that causes platelets to be used up and
the patient can have massive bleeding
– As the inflammation continues, capillaries leak to
release toxins, fluid shifts from the vessels to
interstitial space and the BP drops  SHOCK
Septic Shock
Sepsis
Phase 1
Warm shock
Inflammation
Vasodilation
Ischemia
Tissue Damage
Blood vessels/lungs
ARDS
Phase 2
Cold Shock/ low output
MODS
Death
DIC
Septic Shock
• First Phase
– May last hours or days
– Manage there before it gets worse
– Hyperdynamic, HR up, BP up, bounding pulses,
warm, RR up
– Respiratory alkalosis
– Shift to the left (immature neutrophils)
– Decreased platelets and C reactive protein
(enzyme released in septis and DIC)
– Increased D dimers, why??
Septic Shock
• Second Phase
– Hypodynamic
– Fluid in the lungs may become ARDS (adult
respiratory distress syndrome)- high mortality
– Cold, C.O., BP drop, pulse pressure decreases,
diastolic low, dilated out
– DIC develops, patient is confused or lethargic
– Hypoxia to organs MODS
Treatment of Septic Shock
• Mechanical Ventilation
if hypoxic
• Drugs to increase BP,
dopamine,
epinephrine,
vasopressin
• Heparin for DIC if early,
if late stage, give
Platelets, Plasma and
Clotting Factors (Factor
7 & Cyroprecipitate)
Patient with DIC
Treatment of Septic Shock
• Antibiotics
– Usually multiple
– Drotrecogin alpha or Xigris
may be given as an activated
C reactive protein
– Interleukins, Interferons
• Watch for ARF
• ARDS
• How do you know that the
patient is recovering?
• Would the patient be
acidotic or alkalotic?
• How can you reduce sepsis?
ARDS (Adult Respiratory Distress
Syndrome)
• Acute respiratory failure with:
– Hypoxemia even with 100% O2
– Decreased pulmonary compliance
– Dyspnea
– Bilateral pulmonary edema, noncardiac
– Dense pulmonary infiltrates (ground glass)
• Mortality rate is 50-60%
• Systemic inflammatory response
• Alveolar-capillary
membrane is damaged
• Fluid increases and has
a large amount of
proteins that pull in
more fluid
• Reduced surfactant
and lungs become stiff
and noncompliant
ARDS
• What other processes
besides sepsis can cause
ARDS?
• What will the patient look
like?
• Note if the following is up or
down.
• RR
• BP
• O2 level
• CO2
ARDS
• What is the treatment of choice for a patient
with ARDS?
• What should the paO2 be before intubation?
• What medications may be given for
pulmonary infiltrates?
• What is the main diagnoses related to this
problem?
Emergent Intubation
• Oxygenate patient with
100%
• Laryngoscope is used,
lighted, MD inserts it into
the mouth and looks for the
vocal cords, the tube slides
past over the scope and into
the trachea, above the
carina
Intubation
• ET (endotrachial tube) is
inserted, trach tubes are
placed usually after 7 days
• Cuffed tube that is placed 1
inch above the carina
(bifrucation of the R and L
mainsteam bronchi)
• Patient is medicated with
fentanyl and a paralytic
agent
Intubation Procedure
• Once inserted, you have to
check for placement by:
– CO2 device, turns from
yellow to purple
– Listen to breath sounds
(bilateral)
– Chest X ray
• Tape the tube in place, now
use velcro
• Inflate the cuffed tube and
continue to bag until placed
on ventilator
Mechanical Ventilation
• Two types
– Negative Pressure, non
invasive, body wrap
that puts pressure on
the patient’s body,
they must breathe on
their own
– Positive Pressure,
what is used in the
hospital
Mechanical Ventilation
• During inspiration, pressure is generated that pushes air into
the lungs and expands the chest
– Pressure cycled- preset airway pressure, push air in until
pressure reached, short periods of time, not used much
– Time-cycled- push air into for a period of time
– Volume-cycled-push air in to a preset volume, set to tidal
volume and pressure limits- type commonly used, with
different modes
Volume-Cycled Ventilation
• Set the mode you want to deliver
– Assist-Control- breathes for the patient, tidal
volume and rate are set, if the patient doesn’t
breathe, the vent comes in at the preset rate and
volume, because it is set to deliver a preset rate,
once the patient starts to breathe on their own,
the rate may be too fast. Used mostly when they
come from surgery or if they are nonresponsive
Volume-Cycled Modes
• SIMV (synchronized intermittent Mandatory ventilation)
– TV and rate are preset, but they don’t come in if the patient is
meeting the preset rate and volume
– Positive airway pressure and PEEP may also be set
• PAP refers to a preset airway pressure to keep the bronchioles
open (5-15cm)
• PEEP- positive end expiratory pressure- used to keep the alveoli
open for gas exchange (5 cm)
Ventilator Settings
• Tidal Volume (TV)
– 7-10ml/kg
– Volume of air for each
breathe
– Too high can lead to
barotrauma
• Rate- 10-14/min
• FIO2 (fraction of inspired
oxygen) based on ABG, 21100%, also warmed and
humidified
Ventilator Settings
• Sighs- 1.5-2 x’s the TV
delivered 6-10x’s/hr to
mimic the patient’s
natural sigh, not always
used
• CPAP (continuous
positive airway
pressure), keeps alveoli
open and prevents
collapse on expiration 5-15cm
Ventilator Settings
• Peak Airway Pressure (PIP)
– Pressure needed by the
ventilator to deliver a set tidal
volume
– Highest pressure reached
during inspiration
– Increased PIP may be poor
compliance, patient resistance,
increasing fluid or kinked
tubing
• Flow
– How fast the ventilator delivers
each breathe
– Set at 40L/min
– If agitated may be that the flow
is too low
• I/E ratio
– Inspiratory and expiratory ratio
– Can set to have a longer
expiration to clear CO2 or
longer inspiration to take in
more O2
ARDS settings
• Typical early ARDS settings:
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FIO2- 100%
TV- 500
Rate-14
AC mode
PAP of 10cm
PEEP of 5 cm
• Patient is sedated
• Antibiotics and
Vasopressors are given
Nursing Care for the
Ventilator patient
• Monitor breath sounds,
bilateral, clear, etc
• Monitor Vital signs, BP and
C.O. can drop if the PEEP is
too high, creates too great
a positive pressure and
decreases return to the
heart
• Monitor ABG’s, O2 sats
• Assess the ETT, taped in
place, cuff inflated
whenever on a vent, no
leaks
• Keep patient comfortable,
sedate as needed
Nursing Care for the Ventilated
patient
• Monitor the vent settings,
RT will monitor too and
change along with MD
• Know your vent alarmsalways an emergency
• Ventilator alarms
• High- PIP is too high
• What can cause this?
• Low alarm- can’t meet the
presets
• What causes this?
Ventilator complications
• Cardiac complications
– Hypotension- positive pressures, dehydration and high PIP
– Fluid retention- decreased C.O., ARF, humidified air contributes
• Pulmonary complications
– Barotrauma- pressure damage to alveoli, high PEEP, stiff lungs, can
lead to pneumothorax
– VAP- ventilator associated pneumonia
– Aspiration- often an orogastric tube is placed to suction out
secretions
Ventilator complications
• VAP is a major nosocomial
infection
• 48 hours after placement
• Good aseptic technique
• Inline suction- closed
system
• HOB elevated 30 degrees
• Mouth care
Ventilator complications
• GI and nutritional
complications
– Stress ulcers- give protonix
to all
– Malnutrition- burn a lot of
calories on the vent
– Need electrolyte and calorie
replacement, often corpak
placed for feedings
• Muscle deconditioning
– Become very weak and have
muscle atrophy
• Ventilator dependence
– Inability to wean
– Muscles fatigue and have to
relearn
– Physical and psychological
Weaning
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Process of decreasing vent dependence
Can take a long time, months
Procedure is explained to the patient
Given an antianxiety medication, not a sedative, which would
decrease respirations
• Go from SIMV mode down to PSV (pressure support mode) by
decreasing vent rate and volume.
• On a trach by this time and they may be placed on a T-piece
of vent attachment only at night
Extubation
• Patient must be awake and alert
• Be able to breath on their own, take a
sufficient TV
• Lift their head off of the bed
• Have adequate ABG’s
• Stable hemodynamics (BP and C.O. stable, so
they won’t decompensate)
• Suction before, oxygenate,deflate the balloon
and remove, then suction again