Chapter 66: Critical Care

Question 1

Pts exhibit subtle changes 6-8 hours before a cardiac and/or respiratory arrest.
Critical care nurse, RT, MD, or APN.
Need a transfer to ICU.
See changes earlier so you don’t have to call a code.

Answer 1

RRTs- rapid response teams. Evaluate patient

Question 2

Transition between ICU and general care. Pt needs more monitoring (such as tele) and more constant care. Pt at risk for serious cx but lower risk than ICU pts Only for pts expected to recovery.

Answer 2

PCU- progressive care units (intermediate units, step down units)

Question 3

Critically ill pts:

Answer 3

physiologically unstable. at risk for serious cx. requires intensive and complicated nursing. ONLY for pts expected to recover.

Question 4

Venous thromboembolism d/t immobility. Skin problems d/t immobility. Hospital acquired infection (HAIs)- vents, caths. Sepsis. Multiple organ dysfunction syndrome (MODs)-systemic inflammatory response. Nutritional deficiencies d/t hyper metabolic state or catabolic state (start enteral or parenteral nutrition early-w/i three days). Anxiety d/t threat to physical health, foreign environment, pain, sleeplessness, immobilization, loss of control, impaired communication (work closely with pts, families, caregivers. Encourage caregiver to bring in personal items and photographs. Judiciously use anti anxiety drugs [ie ativan]. Judiciously use massage, guided imagery).

Answer 4

Common problems of ICU pts

Question 5

Pain d/t medical conditions, immobilization, invasive monitoring devices and procedures (continuous IV sedation [ie Propofol (Diprovan) and an analgesic [ie Fetanyl (Sublimaze) but include a daily “Sedation vacation”). Impaired communication d/t use of a sedative or paralyzing drugs, ET tube (always explain what is happening to the pt. Use picture boards, notepads, computer keyboards. Look directly at the pt. Use hand gestures when appropriate. Use an interpreter with non-English speaking pts. Provide comforting touch).

Answer 5

More common problems in ICU pts.

Question 6

Sensory-perceptual problems d/t delirium:
assess for delirium with the confusion assessment method for ICU and the intensive care delirium screening checklist.
Address physiologic factors.
Use clocks and calendars to help orient the pt.
Encourage presence of a caregiver.
May need haloperidol (Haladol)

Answer 6

problem of ICU pts

Question 7

Sensory-perceptual problems d/t sensory overload:
Be cautious with conversations
Mute phones
Set alarms appropriate to the pt’s condition
Limit overhead paging
Limit any unnecessary noise (i.e. IV pump, vent settings, monitors)
Incorporate pt even if unconscious

Answer 7

Problems of ICU pts

Question 8

Sleep problems d/t noise, anxiety, pain, frequent monitoring, treatment procedures:
Structure the environment to promote the sleep-wake cycle.
Cluster activities.
Schedule rest periods.
Dim lights at nighttime, open curtains during daytime.
Limit noise.
Provide comfort measures (i.e. back rubs)
Use benzodiazepines (i.e. Temazepam [Restoril] or zolpidem (Ambien)- be careful with these and use judiciously

Answer 8

Problems in ICU pts

Question 9

Caregivers

Answer 9

Give them guidance and support (they can be going through more than the pt sometimes). Actively listen. Provide them with opportunity to participate in decision making. Involve durable power of attorney for health care if pt is incapable of making decisions. Give convenient access to the pt. Prepare caregivers for the ICU and the pt’s appearance. Provide for the option of family presence during invasive procedures and CPR. Be culturally aware especially in regards to death and dying.

Question 10

Measurement of blood pressure in veins, arteries, and heart, also measures blood flow and amount of oxygen in the blood.
Invasive (internally placed) or noninvasive (externally placed: ECG, BP cuff, SpO2). Integrating and trending all of the data together provides a picture of how well the heart is working and how well tissues are being professed.
Very important to be technically accurate to prevent unnecessary or inappropriate tx.

Answer 10

Hemodynamic monitoring

Question 11

Invasive hemodynamic monitoring

Answer 11

Systemic and pulmonary arterial pressures
PAWP-pulmonary artery wedge pressure
CO/CI- cardiac output/cardiac index
SV/SVI- stroke volume/stroke volume index
SaO2, SvO2
Oxygen saturation

Question 12

Goal of hemodynamic monitoring

Answer 12

Maintain adequate tissue perfusion: early detecting of changes, titration of therapy in unstable pts, determine what organ is causing a problem
Uses: shock (decreases blood pressure-fluid bolus), sepsis (decrease BP d/t 3rd spacing), any loss of cardiac function, burns, surgeries, hemorrhage, dehydration.

Question 13

CO=HR X SV
SV=Preload, afterload, contractility
Preload=volume entering the ventricles
Afterload=resistance left ventricle must overcome to circulate blood

Answer 13

review stuff

Question 14

Increases with high circulating volume, hyper metabolism with hypoxia (heart trying to compensate for hypoxia)
Decreases with low circulating volume (i.e. massive vasodilation seen in sepsis, burns, trauma, shock- decreased preload) or crease in strength of ventricular contraction (MI, CHF)

Answer 14

Cardiac output or cardiac index

Question 15

Volume of blood (mL) ejected with each heartbeat, determined by preload, after load, and contractility.

Answer 15

Stroke volume

Question 16

Measurement of the percentage of blood leaving your heart each time in contracts. Normal is 60-75%

Answer 16

Ejection fraction

Question 17

Strength of contraction.
When increased, stroke volume and oxygen demand are increased.
Increases with positive interpose (i.e. epinephrine, norepinephrine, isoproteneronol, dopamine, dobutamine, digitalis)
Decreases with heart failure, alcohol, negative interpose (i.e. calcium channel blockers, beta blockers), acidosis

Answer 17

Contractility

Question 18

Volume in the ventricle at the end of diastole
Increases with fluid overload
Decreases with hypovolemia and vasodilation

Answer 18

Preload
PAWP will show us LEFT ventricular preload
CVP with show us RIGHT ventricular preload

Question 19

Resistance the ventricle has to overcome to send blood to the body (SVR) or the lungs (PVR).
When ___ is increased, the cardiac output is decreased.
Increased SVR with HTN, hardened arteries, CAD, low volume, catecholamines
Increased PVR with pulmonary HTN (right heart failure), hypoxia (vasoconstriction of pulmonary arteries), PE (increased pressure)
Decreased SVR with vasodilators (i.e. morphine, nitrates), acidosis
Decreased PVR with oxygen, calcium channel blockers, aminophylline, isoproteronol

Answer 19

Afterload
Systemic vascular resistance- opposition encountered by the left ventricle
Pulmonary vascular resistance- opposition encountered by the right ventricle

Question 20

Equipment needed for hemodynamic monitoring

Answer 20

Indwelling intravascular catheter: intraarterial catheter, 1 lumen. central venous catheter, single or multi-lumen. pulmonary artery catheter, 4 or 5 lumens.
Pressure bad and tubing with a flush device and solution.
Pressure transducer
Cables for lumens
Bedside monitor

Question 21

Lumen into artery- radial, brachial, ulnar, avoid femoral

Answer 21

arterial line

Question 22

Increase pressure until it gets to 300 to ensure that there is at least 3-5 ml of fluid through the line per hour. If there is no pressure blood can back up into the line

Answer 22

pressure bag

Question 23

At initiation and with every reading:
position pt supine or up to 45 degrees
Leveling (to the heart)- positioning the zero reference point (stopcock nearest the transducer) to the phlebostatic axis (level of the right atrium), mark on the pt with a permanent marker (4th ICS, midaxillary line)
Zeroing the transducer (to atmospheric pressure)- opening the reference stopcock to air (off to the pt), set the monitor to 0, close the stopcock to air and open to the pt
Obtain results at the end of expiration (respirations affect readings)

Answer 23

Principles of hemodynamic monitoring

Question 24

Every shift:
Fast-flush square wave test (dynamic response test) to ensure accurate waveforms
Ensure pressure bag is inflated to 300 mmHg and infusing at 3-6 mL/hr.

Answer 24

Principles of hemodynamic monitoring

Question 25

Every 3 days:

Change pressure tubing, flush bag, and transducer

Answer 25

Principles of hemodynamic monitoring

Question 26

Allows us to take pressure in artery and change to electrical signal to be read on monitor as BP

Answer 26

Transducer

Question 27

Bolus of fluid into artery to ensure that the line is flushed

Answer 27

Fast flush device

Question 28

When the aortic valve is closed (as seen on the ECG)

Answer 28

dicrotic notch

Question 29

Purpose: continuous measurement of BP (systolic, diastolic, MAP), also allows frequent ABG/blood sampling
Before insertion, ensure pt has a positive Allen test prior to insertion (ensure patency of artery)
Look for normal waveform- dicrotic notch (systolic pressure) should be after QRS on ECG
Complications: infection, impaired circulation (check pulses, cap refill, color q1hr), hemorrhage, emboli

Answer 29

Arterial lines

Question 30

Clinical parameter most often used to assess perfusion.
More accurate than BP along since systolic BP is affected by ventricular function and diastolic BP is affected by peripheral vasoconstriction.
Tells us about blood flow to organ and tissues.
(Diastolic x 2)+ (Systolic) divided by 3
Needs to be >60 to perfuse the vital organs
Normal is 70-105=properly perfusing body

Answer 30

Mean arterial pressure=MAP

Question 31

Purpose: for pts with significant alteration in fluid volume, measures filling pressure of right side of the heart
Placed in the SC, IJ, or femoral while in Trendelberg position (to prevent air emboli), may be asked to hold their breath, CVC is threaded so that the tip rests in the superior vena cava
Single or multi-lumen catheters
Can give IV fluids and draw venous blood (SvO2)
Complications: tension pneumothorax, air embolus, thrombus, infection.

Answer 31

Central venous pressure monitoring

Question 32

Approximates right ventricular filling pressure (blood in the right atrium) (NOT a good indicator of left ventricular problems).
Tells us about right ventricular function and general fluid status.
Increased with fluid overload, right-sided heart failure, pulmonary HTN
Decreased with hypovolemia, decreased venous return (i.e. extreme vasodilation, shock)
Frank-starling law: more preload (increased fluid)=increased stretch=increased contraction
Tells us the amount of fluid in the RIGHT side of the heart
End-diastolic pressure=preload
Normal is 2-8 mmHg

Answer 32

central venous pressure (CVP)

Question 33

Measurement of the oxygen that is left in the blood to determine oxygenation/perfusion. Read through the CVP line (because it sits in the superior vena cava)
Alkalotic state: increased affinity for O2, won’t deliver to tissues=high value
If increasing from low=improvement
Acidosis=decreased affinity for O2=low value

Answer 33

SvO2

Question 34

Multiple ports.
Right atrium/ventricle: CVP/RAP (right atrial pressure) monitoring (2-8 mmHg). Medication/fluid administration. Blood sampling. SvO2. Temp. CO thermo monitoring.
Pulmonary arterial pressures.
Pulmonary arterial wedge pressures (normal 6-12 mmHg)
Measurement of left ventricular preload.

Answer 34

Pulmonary artery catheter (Swan-Ganz)

Question 35

Used temporarily or permanently to decrease ventricular work and improve end-organ perfusion: bridge to transplant (most common use). destination therapy for those who are ineligible for a transplant. bridge to recovery
Requires no immunosuppression, but does require anticoagulation medications
Goal is to improve cardiac output without increasing the work of a failing heart
Intraaortic balloon pump (IABP)- most commonly used
Ventricular assist device (VAD)

Answer 35

Circulatory assist devices

Question 36

Balloon is placed in the descending thoracic aorta above the renal arteries. Balloon fills with helium at the start of diastole and deflates before systole (triggered by the ECG), counterpulsation- inflates opposite to ventricular contraction, inflates with every heart beat
Nursing care- heparin, HOB

Answer 36

Intraaortic balloon pump (IABP)

Question 37

Trying to get the coronary arteries to get blood to the myocardium. Balloon inflates during diastole to push blood into the coronaries, deflates during systole (counter pulsation).
Can become anemic, have elevations in K+ d/t RBC damage.
When the balloon uninflates there is a decrease in afterload=decrease in SVR

Answer 37

IABP

Question 38

Allows more mobility that the IABP.
Placed internally or externally.
Takes blood from the left atrium or ventricle to the device and then to the aorta, may also be used to provide right heart support or biventricular support.
Nursing care: has external controller. Odd heart sounds. BP usually only by doppler. Pulse ox may be inaccurate. May not have a pulse, CPR is often not safe for them. May need to be disconnected for defibrillation. Check neurovascular, pedal pulses, etc.

Answer 38

Ventricular assist device (VAD)

Question 39

What are the appropriate nursing interventions for the pt with delirium in the ICU (SATA):

a) use clocks and calendars to maintain orientation
b) encourage round-the-clock presence of caregivers at the bedside
c) sedate the pt with appropriate drugs to protect the pt from harmful behaviors
d) Silence all alarms, reduce overhead paging, and avoid conversations around the pt
e) Identify physiologic factors that may be contributing to the pt’s confusion and irritability

Answer 39

a) use clocks and calendars to maintain orientation
c) sedate the pt with appropriate drugs to protect the pt from harmful behaviors
e) Identify physiologic factors that may be contributing to the pt’s confusion and irritability

Question 40

The hemodynamic changes the nurse expects to find after successful initiation of inartistic balloon pump therapy in a pt with cardiogenic shock is (SATA):

a) decreased SV
b) decreased SVR
c) decreased PAWP
d) increased diastolic BP
e) decreased myocardial oxygen consumption

Answer 40

b) decreased SVR
d) increased diastolic BP
e) decreased myocardial oxygen consumption