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.
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.”
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:
 Patient’s experience with critical
illness
 Family’s 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
2 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 patient’s wishes
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
Basic monitoring requirements for
seriously ill patients:
1. Heart rate
2. Blood pressure
3. Respiratory rate
4. Pulse oximetry
5. Hourly urine output
6. Temperature
7. Blood gases
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 patient’s physiologic
and psychological needs
Pre arrival Assessment:
- 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
3 Elec II: Acute/Critical Care Nursing
- Admission and critical care - Patient is connected to
documentation forms appropriate monitoring and
support equipment, and critical
medications are administered
Admission Quick Check Assessment

 Appearance (consciousness)
 Airway
 Breathing
 Circulation and cerebral
perfusion, chief complaints
Prearrival Assessment  Drugs
 Equipment
The charge nurse notifies Sue
that she will be receiving a 26-year old Admission Quick Check
man from the ER who was involved in
a serious car accident. The ED nurse - General Appearance
caring for the patient has called to (Consciousness)
give Sue a report. The patient suffered
- Behavior
a closed head injury and chest trauma
with collapsed left lung. The patient - Airway
was intubated and placed in a - Patency
mechanical ventilator. IV access had - Having the patient speak
been obtained, and a left chest tube
had been inserted. After obtaining a Airway
computed tomographic (CT) scan of
the head, the patient will be - Position of the artificial airway
transferred to the ICU. Sue questions
the ED nurse whether the patient has Breathing
been agitated, had a foley catheter
placed, and whether family had been - Quantity and quality of
notified of the accident. respirations
- Rate
Sue goes to check the
- Depth
patient’s room prior to admission and
begins to do a mental check of what
- Pattern
will be needed. “The patient is - Symmetry
intubated so I’ll connect the AMBU bag - Effort
to the oxygen source, check for - Use of accessory muscles
suction catheters, and make sure that - Breath sounds
suction systems are working. The Presence of spontaneous
pulse oximetry and the ventilator are
breathing
ready to go. I have an extra suction
gauge to connect the chest tube
- Wheezes
system. Ill also turn in the ECG - Crackles
monitor and have the ECG electrodes - Rhonchi
ready to apply. The arterial line flush - Stridor
system and transducer are also ready - Pleural friction rub
to B. AdmissionThe
be connected. Quick Check
IV infusion - Presence of spontaneous
devicesAssessment
are set up. This patient has an
breathing
altered LOC, which means frequent
- Obtained immediately after
neuro checks and potential insertion of Chief Complaint
arrival
- Quick overview of the adequacy
- Focuses on primary body stem
of ventilation and perfusion to
involved and the extent of
ensure early intervention for any
associated symptoms
life threatening situation
Circulation & Cerebral Perfusion
Admission Quick Check
- Palpating a pulse
- Focus is on the exploration of
- ECG viewing (HR, rhythm, ectopy)
chief complaint and obtaining
- BP and temperature
essential diagnostic tests to - Peripheral perfusion and capillary
supplement physical assessment refill
findings - Skin color, temperature, moisture
- Seriousness of the problem is - Presence of bleeding
determined - Level of consciousness,
responsiveness
4 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
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 patient’s vital
functions may, at least initially,
take priority over establishing a
precise diagnosis

Common diagnostic tests obtained Initial treatment

during Admission Quick Check
- HR
Assessment
- BP
1. Serum electrolytes - RR
2. Glucose - Temperature
3. Complete blood count with - Hourly UO
platelets - Pulse oximetry
4. Coagulation studies - ABG
5. Arterial blood gases Assessment and Treatment (by body
6. Chest x-ray
system)
7. ECG
- Respiratory system

Evidence-based practice: Family needs - History

assessment: - Dyspnea
- Chest pain
Quick Assessment
- Sputum production
- Offer realistic hope - Cough
- Give honest answers and
information Health History
- Give reassurance
- Inspection
Comprehensive Assessment
- Cyanosis
-
Use open-ended communication and - Breathing
assess their communication style - Increase AP diameter of chest
- Assess family members’ level of - Chest deformities and scars
anxiety - Patient’s posture
- Assess perceptions of the situation
(knowledge, comprehension,
- Position of the trachea
expectations of staff, expected - RR
outcome) - Depth of respiration
- Assess family roles and dynamics
(cultural and religious practices, Inspection
values, spokesperson)
- Assess coping mechanisms and o Duration of inspiration vs.
resources (what do they use, social duration of expiration
network and support)
Equipment o Observation of general
chest expansion
- Evaluate all vascular drainage - Palpation
tubes for location and patency, - Tactile fremitus
and connect them to appropriate - Assess subcutaneous emphysema
monitoring or suction devices - PERCussion
- Note color, consistency, and odor - Assess for dullness and
of drainage secretions hyperresonance
- Verify appropriate functioning of
all equipment attached and label
as appropriate
5 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 – - Medical conditions, surgical

procedures
1. Have you ever had a seizure?
- Psychiatric/emotional problems
2. Have you ever fainted, blacked out, or had
- Hospitalizations
delirium tremens (DT)?
3. Do you ever have numbness, tingling, or - Medications (prescription, OTC,
weakness in any part of your body? illicit drugs) and time of last
4. Do you have any difficulty with your hearing, medication dose
vision or speech? - Allergies
5. Has your daily activity level changed due to - Review of body systems
your present condition?
6. Do you require any assistive devices such as Social History
canes?
- Age, gender
Cardiovascular – - Ethnic origin
- Height, weight
1. Have you experienced any heart problems or
diseases such as heart attacks or strokes?
- Highest educational level
2. Do you have any problems with extreme completed
fatigue? - Occupation
3. Do you have an irregular heart rhythm? - Marital status
4. Do you have high blood pressure? - Primary family members/significant
5. Do you have a pacemaker or an implanted others
defibrillator? - Religious affiliation
- Advance directive and durable
Respiratory –
power of attorney for health care
1. Do you ever experience shortness of breath? - Substance abuse (alcohol, drugs,
2. Do you have a persistent cough? Is it caffeine, tobacco)
productive? - Domestic abuse or vulnerable adult
3. Have you had any exposure to environmental screen
agents that might affect the lungs?
4. Do you have sleep apnea? Psychosocial Assessment
Renal –
- General communication
1. Have you had any change in frequency of - Coping styles
urination? - Anxiety and stress
2. Do you have any burning, pain, discharge, or - Expectations of critical care unit
difficulty when you urinate? - Current stresses
3. Have you had blood in your urine? - Family needs
Gastrointestinal – Spirituality
1. Has there been any recent weight loss or gain? - Faith/spiritual preference
2. Have you had any change in appetite? - Healing practices
3. Do you have any problems with nausea or
vomiting? Physical assessment
4. How often do you have a bowel movement and
has there been a change in normal pattern? Do - Nervous system
you have blood in your stools?
- Cardiovascular system
5. Do you have dentures?
6. Do you have any food allergies? - Respiratory system
- Renal system
Integumentary - Gastrointestinal system
- Endocrine, hematologic, and
1. Do you have any problems with your skin? immune systems
Endocrine - Integumentary system

1. 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
6 Elec II: Acute/Critical Care Nursing

Peripheral Pulse Rating Scale

0 = Absent pulse

Identification of Symptom Characteristics +1 = palpable but thread; easily

obliterated with light pressure
Characteristic Sample Questions
+2 = Normal; cannot obliterate
Onset - how and under what
circumstances did it begin? Was the with light pressure
onset sudden or gradual? Did it progress?
+3 = Full
Location – where is it? Does it stay in the
same place or does it radiate or move +4 = Full and bounding
around?

Frequency- how often does it occur?

Quality – it is dull, sharp, burning, Auscultation

throbbing, etc?
- Vesicular
Intensity- rank pain on a scale (numeric,
word description, FACES, FLACC)
- Bronchovesicular
- Bronchial
Quantity- how long does it last? - Tracheal
Setting- what are you doing when it
- Egophony
happens? - Whispered pectoriloquy

Associated Findings- are there other signs Adventitious breath sounds

and symptoms that occur when this
happens? Auscultation pattern
Aggravating and alleviating factors- what Respiratory Support: All seriously ill
things make it worse? What things make patients without pre existing lung
it better?
disease should receive supplementary
oxygen at sufficient concentration to
maintain arterial oxygen tension
60mmHg or oxygen saturation of at
least 90%
Edema Rating Scale
The results of blood gas analysis alone
Following the application and
is rarely sufficient to determine the
removal of firm digital pressure
need for mechanical ventilation. Several
against the tissue, the edema is
other factors have to be taken into
evaluated for one of the following
consideration.
responses:
Factors to consider for the need of
0 = no depression in tissue
mechanical ventilation:
+1 = small depression in tissue,
a. Degree of respiratory work
disappearing in < 1 second
b. Likely normal blood gas tensions
+2 = depression in tissue for that patient
disappears in <1-2 seconds c. Likely course of disease
d. Adequacy of circulation
+3 = depression in tissue
disappears in <2-3 seconds
+4 = depression in tissue
disappears in > or = 4seconds

Evidence-based practice - Sleep

promotion in Critical Care

1. Assess patient’s usual sleeping

patterns
2. Minimize effects of underlying disease
process as much as possible (eg
reduce fever, eliminate pain,
minimize metabolic disturbances)
 7 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);
depression or demoralization; family Ongoing Assessment Template
functioning and needs; ability to
communicate needs and participate Body System Assessment Parameters
in care; sleep patterns
Nervous
Isolation Categories and Related Infection
Examples - LOC; Pupils; Motor strength of
Isolation Categories extremities
Infection examples
when used
Cardiovascular
1. Standard precautions – used - with
Bloodcare
pressure; heart rate and
of all patients rhythm; heart sounds; capillary refill;
2. Airborne precautions – tuberculosis,
peripheral pulses; patency of IVs;
measles (rubeola), varicella verification of IV solutions and
3. Droplet precautions – Neisseria
medications; hemodynamic
meningiditis, Haemophilus influenza,
pressures and waveforms; cardiac
pertussis, mumps
output data
4. Contact precautions- Vancomycin-
resistant enterococcusRespiratory
(VRE),
Methicillin-resistant Staphylococcus
aureus (MRSA), Clostridium - difficile,
Respiratory rate and rhythm; breath
Factors contributing to Sleep Disturbances in scabies, impetigo, respiratory sounds; color and amount of
Critical Care secretions; non-invasive technology
syncytial virus (RSV)
information (eg pulse oximetry; end-
1. Illness
- Metabolic changed tidal CO2); mechanical ventilator
- Underlying diseases (eg cardiovascular parameters; arterial and venous blood
disease, chronic obstructive pulmonary gases
disease (COPD)
- Pain Renal
- Anxiety, dear
- Delirium - Intake and output; color and amount
2. Medications of urinary output; BUN/creatinine
- Beta-blockers
values
- Bronchodilators
- Benzodiazepines
- Narcotics
Gastrointestinal
3. Environment
- Noise - bowel sounds; contour of abdomen;
- Staff conversations position of drainage tubes; color &
- Television/radio amountof secretions; bilirubin &
- Equipment alarms Mechanical Ventilation
albumin values
- Frequent care interruptions
- Lightning ET to VC TV 500 FiO2 40% BUR 14 PEEP
- Lack of usual bedtime routine
- Room temperatrure
5
- Unfomfortable sleep surface
8 Elec II: Acute/Critical Care Nursing
TT to PCV Pinsp 8 FiO2 .6 f18 PEEP 7
Mechanical Ventilation: Delivery of air
into the patient by positive pressure
Manual resuscitation: Nurse’s 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 patient’s 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 patient’s
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
Negative Pressure Ventilators
Iron Lung: Patient’s body encased in iron
cylinder and negative pressure is
generated to enlarge the thoracic cage
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 Assist Control (A/C)
o SIMV
o PSV
o PCV
o IRV
o CPAP
o 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
9 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
Pressure Support Ventilation
- 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
Inverse Ratio Ventilation
- Requires paralysis
- Monitor for auto-PEEP,
barotrauma, hemodynamic
instability
Continuous Positive Airway Pressure
(CPAP)
- Constant positive pressure for
patients who breathe
spontaneously
- Used in intubated and non-
intubated 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)
- 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
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
Mobility and Safety
- 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
- Provide early nutritional support
- Take daily weights
- Avoid high carbohydrate intake
Comfort and Pain Control
- 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
- 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
The need for renal replacement therapy
is determined by:
- 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
Creatinine
- 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
- reabsorption of blood from the
intestines
Blood Urea Nitrogen & Creatinine
- varies inversely with GFR
Neurological System
- 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
- LOC: single most important
indicator of cerebral functioning
- Observation of patient’s
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 a. Pupils
oriented when aroused. b. Shape
- Lethargic: drowsy but follows c. Size and reaction
simple commands when d. Symmetry
stimulated e. Corneal reflex
- Stuporous: very hard to arouse; f. Cranial nerves V and VII
inconsistently may follow simple g. Protective reflex
commands or speak single words h. Brainstem function
i. Gag reflex and ability to swallow
or short phrases
j. Cough reflex controlled by cranial
- Semi-comatose: movements are
nerves IX and X
purposeful when stimulated; does
not follow commands or speak Muscle strength
coherently
- Comatose: may respond with - Neurological history
reflexive posturing when - Recent trauma that could affect
stimulated or may have no the nervous system
response to any stimulus - Recent infections (sinusitis or ear
infections)
Pain stimulus - Feeling of dizziness, loss of
balance, “black-out spells”
Central stimulus - Clumsiness or weakness of
- Squeezing trapezius muscle extremities
- Supraorbital pressure
Neurological history
- Sternal rub
- Sensory distortions (numbness,
Peripheral stimulus
tingling)
- Nail bed pressure - Tobacco, alcohol, and drug use
- Prescription and OTC drugs
AEIOU tips (causes of altered mental
Glasgow Coma Scale status)
1. Eye opening 1. Alcohol
2. Verbal response 2. Epilepsy
3. Motor response 3. Insulin
4. Overdose/oxygenation
Level of consciousness
5. Underdose/uremia
2 components: 6. Trauma
7. Infection
a. Arousal 8. Psychosis
b. Awareness 9. Stroke/shock
Arousal Circulatory Support
- State of wakefulness - An adequate arterial pressure is
- Reflects function of reticular essential for perfusion of major
activating system and brainstem organs and glomerular filtration,
particularly in elderly or
Awareness
hypertensive patients, and for
- Content and quality of sustaining flow through any areas
interactions of critical narrowing in the
- Reflects functioning of the coronary and cerebral vessels
cerebral cortex
Circulatory support
Decorticate posturing (flex)
- Shock represents a failure of
- Damage in the cerebral tissue perfusion
hemispheres or thalamus - It is primarily a failure of blood
flow and not of BP
Decerebrate posturing (extend)
Signs suggestive of shock:
- Damage to the midbrain or pons
1. Tachycardia
Decerebrate or decorticate
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
Peripheral Pulse
- 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
Cardiac dysrhythmias
Electrocardiogram
- Electrical activity of the heart
- Depolarization
- Repolarization
- Not mechanical function of heart
- Contraction
- Relaxation
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
- 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
- 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
- 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 heart’s
activity
- SYNC button must be on
- Detects the patient’s 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 patient’s 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
Cardiac output
- 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 Starling’s 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
- 155-255 dynes.sec/cm5
Increased Pulmonary vascular
resistance
- Pulmonary hypertension
- Pulmonary edema
Systemic Vascular Resistance
- 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 patient’s
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 patient’s 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
o Additional medications to provide the
patient’s scheduled intermittent
medication doses and to meet
anticipated needs (eg sedation) with
appropriate orders to allow their
administration if a physician is not
present
o 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
o 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.