Critical Care Concepts & critical care environment Part 3

Slide 1:
Welcome to Part 3 of critical care concepts and the critical care environment. Please be sure you
have the handout ready before beginning this presentation. In this presentation, we will discuss
other types of interventions frequently used in the critical care setting.

As mentioned in the first lecture, critical care pts are often unstable, requiring frequent
monitoring & assessment of multi-organ systems. Let's look at some interventions, procedures,
and equipment related to the various systems.

Slide 2:
Cardioversion is a synchronized electrical shock performed in emergencies for unstable atrial
and ventricular dysrhythmias, such as atrial fibrillation, atrial flutter, or ventricular tachycardia.
Cardioversion is used to slow the heart or restore the heart’s normal sinus rhythm when drug
therapy has been ineffective in converting the abnormal rhythm. The term synchronized means
the shock is coordinated with the QRS complex on the pts EKG. A machine called a defibrillator
is used to deliver the electrical shock. The shock is intended to stop the abnormal rhythm,
allowing the sinus node, which is the heart’s pacemaker, to regain control.

Cardioversion is done either as a scheduled procedure, or as an emergency. A physician explains

& performs the procedure. In a non-emergent situation, a consent form is completed and the pt
sedated with intravenous midazolam (Versed), or a short-acting anesthetic. In an emergency,
there may not be time to complete a written consent or sedate the pt.

IV access is established and emergency equipment must be available during the procedure.
Electrodes or pads are placed as shown in the picture; one over the upper right chest, just under
the clavicle, next to the sternum, and the other on the left lower chest, just lateral to the
precordium. When the shock is delivered, all healthcare personnel must stand clear of the pt to
prevent being shocked themselves. The person in charge will loudly shout to stand clear of the pt
and bed to ensure safety for all involved.

After the procedure, assess the pt for the return of a normal sinus rhythm by observing the
monitor and completing an assessment, including airway, LOC, & VS. Administer oxygen as
needed. Assess the skin for redness or burns, administer ordered antidysrhythmic medications,
document the procedure, and provide emotional support to the pt & family.

Energy levels used to deliver the shock can starts low, at 50 joules, and can increase to 120-200
joules if needed. A joule is a unit of energy in the metric system.

Slide 3:
Defibrillation is an asynchronous electric shock delivered to treat pulseless ventricular rhythms
such as pulseless ventricular tachycardia or ventricular fibrillation, also termed Vtach & Vfib.
Pts in pulseless Vtach or Vfib have no cardiac output and are in cardiac arrest. The goal of
defibrillation, as in cardioversion, is to stop the heart's quivering or fibrillating, and restore a
normal sinus rhythm. Early defibrillation is critical in converting pulseless VT or Vfib to a
normal, perfusing rhythm and must be performed as quickly as possible by a trained healthcare
professional. Nurses in critical care units learn how to properly defibrillate pts in emergencies.

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Defibrillator pads are placed in the same location as with cardioversion, as noted in the upper
picture on the slide. Defibrillator paddles are placed over the pads to deliver the shock. Many
newer defibrillators are hands-free, similar to an AED. As with cardioversion, the person
defibrillating the pt must ensure all personnel are clear of the pt & bed to maintain electrical
safety. After defibrillation, CPR is continued for two minutes if needed and antiarrhythmic
medications are administered. After two minutes, the rhythm is reassessed and defibrillation
repeated if warranted. Nursing care of the pt after defibrillation is the same as for cardioversion.
There are a variety of YouTube videos that demonstrate cardioversion & defibrillation if you are
interested.

Automatic external defibrillators or AEDs, as seen in the lower picture on the slide, are used by
laypersons and healthcare professionals in cardiac arrest situations. AEDs are found in many
public places, such as airports, malls, schools, stadiums, & on airplanes. AED are located on the
Tri-C campuses. Have you seen them? Where are they located?

With a push of the power button, AEDs provide step-by-step instructions on how to use the
machine, and when to shock the pt. You should have learned how to use an AED in your CPR
class. Using AEDs provide for early defibrillation, and a greater chance for pt survival.

Slide 4:
Defibrillators are classified as either monophasic or biphasic. Monophasic defibrillators deliver
current in only one direction and require higher joule levels, such as 360 joules. A biphasic
defibrillator sends current from one pad to the other, then back again, delivering shocks at lower
levels, 200 joules. We will discuss cardioversion and defibrillation more when learning how to
interpret EKGs and treat abnormal heart rhythms.

Slide 5:
Circulatory assist devices are used in pts with end stage heart failure that no longer respond to
medications. The goal of circulatory assist devices is to improve myocardial tissue perfusion and
decrease the workload of the heart. Lets look at two types: intra-aortic balloon pumps (IABP)
and ventricular assist devices.

An IABP is used to improve myocardial perfusion by increasing coronary artery filling, reduce
preload and afterload, and aid left ventricular ejection or cardiac output.

Look at the image on the lower left. Inserted surgically, through the femoral artery, the balloon
catheter in threaded into the descending aorta. Now look that the pictures on the right. During
diastole, when the ventricles are filling with blood, the balloon inflates, increasing blood flow to
the coronary arteries by blocking the aorta, forcing blood back into the coronary arteries, thereby
improving coronary perfusion. During systole, when the ventricles contract, the balloon deflates,
reducing afterload, and creating a vacuum affect that improves left ventricular ejection and
cardiac output. Afterload is the pressure or resistance the ventricles must overcome to eject
blood. The balloon catheter is attached to a pump, which is triggered by patient’s EKG and
arterial waveform. IABP support is used until the heart is improved enough to work on its own.

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Slide 6:
Ventricular assist devices are also used to treat end stage heart failure with the goal of improving
cardiac output. Look at the upper picture on the slide. VADs can be used short-term, as a bridge
while pts wait for a heart transplant or used long-term, for pt with heart disease, unresponsive to
medications or surgery. VADs are implanted to work with the pts own heart and can be used for
R & L sided heart failure, or complete (bilateral) failure. VADs that treat left-sided failure are
more common and have a tube that pulls blood from the left ventricle into a pump. The pump
then sends blood into the aorta. This effectively helps the weakened ventricle. The bottom
picture shows a long-term device with four implantable parts.

Slide 7:
Intracranial pressure monitoring devices are used to determine intracranial pressure (ICP), or the
pressure within the cranium. Remember, the cranium, or skull, is a solid boney structure that
cannot expand if there is increased mass within the brain. Increased mass or volume can occur in
a variety of neurological disorders, such as with tumors, intracranial bleeding, or with cerebral
edema. If intracranial pressure becomes too high, severe brain damage or death can occur. An
ICP catheter is inserted through a Burr hole, which is a hole drilled into the skull. The catheter is
attached to a transducer that converts ICP to electrical impulses that can be viewed as a
waveform on a monitor or as a digital readout. The picture of the monitor on the slide shows an
ICP waveform.

There are different types of ICP devices as noted in the upper picture. You will learn more about
these devices during the neurological unit later this semester. One of the biggest concerns, with
all types of intracranial catheters, is infection. Therefore, strict aseptic technique must be
maintained when handling these devices.

Nurses monitor ICP and intervene based on written protocols. Mannitol (Osmitrol) is an osmotic
diuretic used to treat elevated ICP. This medication is discussed in your pharmacology readings
this week.

Slide 8:
A restorative measure for the renal system is hemodialysis. Let’s briefly discuss hemodialysis
catheters. This is review from previous semesters. A Quinton catheter is a double lumen dialysis
catheter used for pts with acute or chronic renal failure requiring hemodialysis. The catheter
functions as a temporary device in pts with acute renal failure, and in pts with chronic renal
failure waiting for fistula maturation. A PermaCath, shown on the right, is used for long-term
vascular access. Quinton catheters, like other dialysis catheters, have two lumens, designed to
allow arterial and venous flow through one catheter. They are typically inserted into the jugular
or subclavian veins, similar to other types of central lines. However, these catheters are used
solely for hemodialysis and should never be used for regular venous access and fluid
administration. The picture on the left shows a subclavian insertion of a dialysis catheter.

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Slide 9:
Esophagogastric balloon tamponade is a short-term solution for treating severe hemorrhage from
esophageal varices. The term tamponade means to stop the flow of blood by pressure or
compression. Sengstaken-Blakemore tubes, as shown in the slide, and Minnesota tubes are thick
catheters, placed through the nose into the stomach, similar to a nasogastric tube. These special
catheters have two balloons used to apply pressure to stop hemorrhaging from esophageal
varices. The image on the left of the picture shows the two balloons inflated, one in the stomach
that applies pressure upward on the cardiac sphincter, the other along the length of the esophagus
that exerts pressure on the esophageal wall. Once inserted, a stat CXR is done to confirm
placement. Sengstaken-Blakemore & Minnesota tubes are used as a last resort to treat pts
unresponsive to traditional therapies. Pts should be intubated and placed on a mechanical
ventilator to protect the airway, prevent obstruction from the tube, and prevent aspiration of
secretions or blood. You will learn more about Sengstaken-Blakemore tubes during the GI unit.

Slide 10:
Parenteral nutrition is the administration of nutrients by a route other than the digestive tract.
Parenteral nutrition is used in pts who are unable to eat an adequate diet, are NPO for a
prolonged period, or are unable to use their digestive tract for nutrition. The goal of parenteral
nutrition is to improve the nutritional status of the pt and promote healing. These pts usually
have increased caloric needs for a variety of reasons. For example, a pt recovering from severe
burns, or a pt with sepsis will need increased calories to meet high metabolic demands.
Parenteral nutrition is given intravenously in a solution containing glucose, amino acids,
electrolytes, vitamins, minerals, & fat. Parenteral nutrition can be given through a peripheral
catheter or a central line. When given through a peripheral catheter, it is termed PPN or
peripheral parenteral nutrition. In this instance, the solution contains a lower percentage of
glucose, around 10% dextrose, and has a lower osmolarity. Hyperosmolar solutions, with a
higher percentage of glucose, must be given through a central catheter. This is termed total
parenteral nutrition or TPN. The picture in the slide shows TPN through the subclavian vein. Pts
receiving parenteral nutrition require special care. You will learn more about TPN in the
digestive unit at the end of the semester.

Slide 11:
The last topic is restorative interventions related to the musculoskeletal system. This focuses on
the prevention of complications in the critically ill due to prolonged bedrest & immobility. Some
of those complications include skin break down, joint stiffness, muscle atrophy, loss of
endurance, & blood clots or DVTs. Immobility can also lead to psychosocial complications such
as sensory alterations, decreased coping, and behavioral changes. Adequate rest is extremely
important for the body to heal and recover from any illness. In the critically ill pt, continuous
monitoring, bright lights, beeping monitors, and frequent nursing interventions greatly interfere
with the pts ability to rest, leading to sleep deprivation and delirium. Nurses must evaluate each
pt individually, and create a plan of care that allows for periods of uninterrupted rest. Nurses
must construct a plan that balances the pts need for rest, with the implementation of nursing
interventions that prevent musculoskeletal and other complications. This slide lists possible
complications of bedrest. Take a moment and consider some nursing measures, learned in your
fundamentals course, that help prevent the negative effects of bedrest. Hopefully you are
thinking about

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• Maintaining proper body alignment

• Frequent turning q 1-2 h
• Active & Passive range of motion exercises
– Consulting with physical therapy
• TED hose, PAS stockings
• Orthopedic appliances
– Splints
– Footboards
– Special boots

Slide 12:
This concludes part 3 of critical care concepts and the CC environment. Please complete the
assigned readings and answer the questions at the end of this handout to ensure you understand
the information.

Review questions:

1. Compare and contrast cardioversion and defibrillation.

2. How would you explain an IABP or a VAD to a pt and/or family member?

3. List the action and nursing interventions for the emergency medication used to treat elevated
ICP.

4. What is the goal of parenteral nutrition? Describe the difference between PPN & TPN.

5. List several nursing interventions to prevent complications related to immobility and bedrest.

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