Fundamental Care

Needs in Critically Ill

Patients
Nadia Rohmatul Laili
Fundamental Needs
• Effective communication
• Respect and dignity
• A care environtment that meets needs and preferences
• Safety
• Food and drink
• Prevention and management of pain
• Personal hygiene
• Maintenance of skin and underlying tissues
• Bladder, bowel and continance care
• Control over their care
• Health and wellbeing
• Record keeping that promotes high-quality care
PERSONAL
HYGIENE
Personal Hygiene
Mouth Care
Problems in critical illness:
• Xerostomia (dry mouth)
• Trauma from oral intubation
Xerostomia in critically ill
patients
• Lack of saliva
• Factor that contribute to xerostomia:
 Dysphagia
 Absence of oral intake
 Convection
 Side effect of drugs, ex:opioid, diretics, noradrenaline
• Increases the risk of oral infections and accelerating tooth
decay
Trauma from oral intubation
• Loose teeth
• Pressure on parts of the oral cavity, including
tongue
• Tapes, can cause trauma, sores and lacerations
Assessment of oral cavity
• Oral cavity (all parts, especially tongue) Colonization by
microorganism
• Lips  Ulceration
• Teeth  Damage, caries
• Gums  gingivitis, bleeding
• Salive  Excess, Lack of, High viscosity
• Tongue  Dark colour, dry
• Hard palate  Bleeding, ulceration
• Soft tissue  necrosis
Care of Oral Cavity
• Regular moisturizing mouth
• Apply a lubricant
• Humidify face-mask oxygen
• Clean teeth with toothbrush
• Moisten mouth if dry
 Daily Oral care
• Oral assessment every
shift
• Brushing teeth, tongue
and gums with a soft
toothbrush (minimally
twice daily)
• Swabs are not effective
at removing plaques
 Daily Oral care
• Moisturizing agent for
mouth
• Antiseptic rinse
• Chlorhexidine
decontamination of
mouth
 Daily Oral care
• Routine suctioning of
mouth to manage oral
secretions and
minimize risk of
aspiration
Eye Care
• Problem in critically ill patients:
 Keratitis (corneal inflammation)
 Blepharitis (inflammation of eyelash follicles
and sebaceous glands)
Factor that expose eyes to potential damage in critical care:

• Inability to protect own eyes

• Impaired tear production, by drugs (atropine, antihistamine)
• Intraocular hypertension, may be caused by positive pressure
ventilation, hypercapnia, anything impeding venous return from
cranium
• Drying with oxygen from face mask
• Deep sedation, which impairs blink reflexes and possibility tear
production
• Trauma for equipment (ventilator tubing, tapes, linen)
Assessment
• Eyelid (fully close, absent blink reflex)
• Conjunctiva (ulceration, infection, pain)
• Tears (adequate or not)
• ‘crusts’ at corner of eye or on eyelid
• Surrounding muscle (weakness)
• Retina (seeing flashing light, visual defect)
Prevention
• Regular cleaning of eye
• Ensure ventilator tubing, ETT tapes or other equipment is kept
away from eyes
• If infection is suspected, swab infected area for microbiology
culture
• Remove with sterile swabs and water, to prevent crusts
• Consider need for regular eye drops
• Use a new swab for each eye
NUTRITION
Hydration and Nutrition Status
Critical illness  stressor

• Arterial and venous pressure and volume

• pH
• Osmolality
• Pain
• Anxiety
• Arterial oxygen content
• Toxic mediators from infection and tissue injury

Stimulating metabolic response

Metabolic Response
‘Ebb’ phase
• Immediately
• 12-24 hours
• Hypoperfusion of the tissues
• Reduced metabolic activity
• Hyperglycaemia
• Release catecholamines to
increase HR
• Contractility and
vasoconstriction to improve
cardiac performance
• Restoring an adequate blood
pressure
‘Flow’ phase
• Restoration of blood flow
to the tissues
• Delivering oxygen and
metabolic substrates
• Increase level of hormones
(catecholamines, glucagon,
cortisol)
• Catabolism of the
pheripheral muscles and
adipose tissues
• Considerable loss of muscle
• Reduced carbohydrate and
fat stores
Hydration
• Capilary leak syndrome
• Cellular disfunction
• Substantial fluid loss
Hidration and nutrition status in
critically ill patients
May caused by:
• Patients may be unable to drink and eat
• Patients may be catabolic and nutritional replacements may
not be adequate to replace metabolic losses
• Patients may have impaires ingestion due to neurological or
other condition
• Patients may have impaired absorption
Fluid input and output sources
Input Output
Oral (drinks and food) Faeces

Enteral Gastric secretions (gastric

drainage, gastric aspirations,
Intravenous fluids (parenteral, vomit)
infusion and drugs)
Urine

Insensible lossess

Wounds and drains

Net losses during renal

replacement therapy
Assessment of fluid status
• History
• Thirst
• Mucosa and conjunctiva
• Clinical sign (HR, BP, CVP, RR, CRT, urine output, skin turgor)
• Serum electrolyte level (Sodium, potassium, urea, creatinine)
• Temperature
Maintaining Nutrition
Assessment, are to:

• Determine the existing nutritional status

• Identify if the patients is malnourished
• Provide a baseline for monitoring nutritional status
• Ascertain the patient’s nutritional requirement
Nutritional assessment
• A 24-hour recall of dietary intake
• A diet history
• Food preferences
• Food allergy
• Portion sizes and changes in food intake
• Anthropometric assessment (weight, triceps’ skinfold
thickness)
• Serum albumin levels
Factors that can affect nutritional
status
• Inability to take oral diet
• Vomiting and diarrhoes
• Constipation
• Glucose intolerance
• Renal dysfunction
• Pain
• Nausea
• Physical disability
• Restricted fluid intake
• Delayed gastric emptying
• Reduces gut motility
• Fasting before procedures/investigatons
 Enteral Feedings
• Initiation of safe
enteral nutrition
within 24-48 hours of
ICU admission
• Early initiation
decreases bacterial
colonization
• HOB 30-45°

85% of critically ill patients can be

successfully fed via the enteral route
Benefits enteral feeding
• Improved function of the gut and liver
• Reduced incidence of stress ulceration and GI bleeding
• Maintainance of gut integrity and preservation of the gut as a
barrier
• Enhanced immune fuction, reduced infection rates and lower
sepsis rates
• Improved survival rate in criically ill patients
• Increase gastric mucosal blood flow
• More closely matched to normal physiology
• Less expensive than parenteral nutrition
Best practice – enteral Feeding
• Adhere to best practice feeding protocols
• Commence enteral nutrition within 24 hours of injury or ICU admission
• Calculate nutritional needs based on metabolic demand
• Always confirm tube position before commencement of feed
• Always flush tubes before and after administration of medications
• Monitor tube position during feeding regularly
• Monitor the patient’s vital signs, particularly the airway
• Keep head of the bed elevated to 30-45° while administering feed
• Increase feed to meet nutritional requirements following local guidelines
• Ensure feed is in date and administered following manufacture’s recommendations
• Monitor absorbtion of feed
• Always use clean oral syringes not IV syringes and receptable when aspirating
• Maintain fluid balance
• Maintain bowel function
• Monitor patient’s blood chemistry
Complication of enteral feeding
• Regurgitation and aspiration of gastric contents
• Tube obstruction
• Diarrhoea
• Abdominal distension
• Hyperglycemia
• Mild hepatic dysfunction
Total Parenteral Nutrition
• Considered only when enteral nutrition is contraindicated
• Indication of TPN:
 Ileus
 Acute pancreatitis
 Inflammatory bowel syndrome
 Short bowel syndrome
 Malabsorbtion syndromes
 Multiple organ dysfunction syndrome
 Post-oesophagectomy
 Severe catabolic states, ex: extensive burns, sepsis and trauma
Best practice – parenteral
feeding
• Only use when enteral feeding is not possible
• Do not use feed bag if there are signs of contamination
• Administer feed following local protocols
• Ensure that entire infusion line is dedicated to parenteral nutrition use
• Ensure that feed and tubing are regularly changed
• Never add anything to a bag of TPN
• Monitor blood sugar 2-hourly when first initiated
• Monitor patient for complications of parenteral nutrition
• Regularly fluxh line when not in use to maintain patency
• Monitor gut function so that the enteral feeding can be started as soon
as possible
Risk during TPN
administration
• Significant risk of comorbidity through sepsis
• Metabolic problem
• Mechanical problems (pneumothorax, bleeding, thrombus
formation, sepsis, catheter related)
• Rebound hypoglicaemia if TPN are abruptly stopped
 Stress Ulcer
Prophylaxis
• Sucralfate, H2
receptor blocker and
proton pump
inhibitor – increases
gastric ph and
minimize bacterial
colonization and
reduces risk of VAP
Glycaemic control
Metabolic stress Hyperglicemia leads to polyuria,
dehydration, hypotention,
electrolyte imbalance, nausea and
Release of cortisol, vomiting
catecholamines and
glucagon

Stimulates the Check blood glucose at

breakdown of fat and least 4-hour after
glycogen infusion

Rise in blood sugar

Problems with providing hydration
and nutrition
• Overfeeding
 Too large calories  increase CO2 production and retention
 Carbohydrate  steatosis of liver, increase Co2 and
hyperglycaemia
 Fat  lipid deposits in the lungs impairing gas exchange, impaires
the reticular endotheial system
 Protein increase rate of protein synthesis
• Refeeding syndrome
SLEEP
Sleep

Why is sleep
importance ??
The stages of sleep
Sleep disruption factors in critically
ill patients
• Severity of ilness
• Mechanical ventilation
• Noise
• Light and darkness
• Ambient temperature
• Clinical interventions and prosedures
• Medication
• Pain and stress
Sleep deprivation in critical care
patients
• Behavioral changes, such as irritability, restlessness, tiredness
and disorientation
• Psycotic behaviour
• Confusion
• Decrease pain tolerance
• Long-term health problems and an increase in patient
morbidity
• Stress
• Development of delirium
• Delayed recovery from ilness
Sleep Promotion Strategy
• Ensure the ventilation tubing is free from excess water
• Set alarm limits appropriate to prevent unnecessary high
alarm noise
• Ensure staff discussion are kept to a minimum away from the
patients’ bed
• Consider drawing curtains arround the patients
• Adjust room temperatures and/or air conditioning to ensure
patient comfort
• Assess and treat with the most suitable pain relief
• Ensure the patient’s anxieties or worries are minimized
PRESSURE ULCERS
Pressure Ulcers
• More likely to remain longer in the unit
• Survival rate are reduced
Factors correlating pressure
ulcers
• Severity of ilness
• Poor tissue perfusion due to haemodynamic instability
• Co-morbidities
• Use inotropes
• Renal replacements therapy
• Malnutrition
• Hyperpyrexia
• Faecal incontinence
• Immobility
• Use of sedatives
Additional risk for critically ill
patients
• Pre-existing trauma or surgical wounds
• Mechanical damage to eyes, when the patients is lying in a
prone position
• Prolonged occipital pressure (head resting back on pillows)
• Areas in contact with ETT or tracheostomy tapes
• Any parts of the body near or on cables, tubing, or other
equipment
Stage
Pressure ulcers
Assessment
Braden
Scale
Skin inspection
• Persistent erythema
• Non-blanching hyperaemia
• Localized induration
• Purplish/bluish localized areas
• Localized coolness
• Blisters
• Localized heat
• Localized oedema
Prevent Pressure Ulcers
• Maintaining good hygiene and avoiding maceration of skin
• Optimizing hydration
• Optimizing nutrition
• Optimizing oxygenation
• Pressure redistributing equipment
• Positioning, reducing shear and friction
Healing pressure ulcers
• Minimize or remove pain
• Promote healing
• Prevent infection from microorganism in the
atmosphere surrounding skin surface
THANK YOU