Critical Care APN Flashcards
NIV/HFNC is in another deck
What is a central venous catheter?
An indwelling catheter in a large central vein
Indications for central venous catheter
- Infusions incompatible with peripheral access i.e.
vasopressors, TPN, chemo - Venous access in emergency/difficult peripheral
access - Central venous pressure monitoring
- Initiation of extra-corporal therapies i.e. renal replacement therapy, plasmapheresis
- For venous interventions i.e. trans-venous pacing, intra-venous stenting etc.
ABSOLUTE contraindications for central venous catheter
active skin infection @ insertion site
vascular injury at site
presence of device at site
Relative contraindications for central venous catheter
Bleeding risk
Uncooperative awake pt
Trauma/Congenital anomalies @ site
Morbid obesity
5 main complications of central venous catheter
- Pneumothorax post insertion
- Occlusion from clot formation
- Central Line Associated Bloodstream Infection / site infection
- Air embolism (can occlude blood flow)
- Dislodgement or migration of catheter
(Pneumothorax - Central Venous Catheter Complications) Assessment
Observe for signs of pneumothorax
(Pneumothorax - Central Venous Catheter Complications) Prevention/Nursing Intervention
- Positioning during insertion: SUPINE/TRENDELENBURG
- Prepare for chest tube insertion
(Occlusion from clot formation - Central Venous Catheter Complications) Assessment
Check for backflow & ability to infuse
Assess CVC for unclamped unused lines
(Occlusion from clot formation - Central Venous Catheter Complications) Prevention/Nursing Intervention
- routine flushing as per SOP
- do not flush against resistance
- keep free from kinks
- do NOT MIX MEDS that can have PRECIPATION
(Infection - Central Venous Catheter Complications) Assessment
Assess catheter insertion site & surrounding area
monitor lab results
(Infection - Central Venous Catheter Complications) Prevention/Nursing Intervention
- ASEPTIC technique
- CLABSI prevention bundle: valved needleless connectors, CHG dressing, CHG/antibiotic coated catheters, early removal
- early detection & treatment of CLABSI
(Air embolism - Central Venous Catheter Complications) Assessment
- Monitor for S&S of air embolism: SOB, chest pain, altered mental status, seizures, LOC, cardiovascular collapse
- Assess CVC for exposed hubs and unclamped
unused lines
(Air embolism - Central Venous Catheter Complications) Prevention/Nursing Intervention
- Use valved needleless connectors
- Do not expose hubs to air
- Clamp line when not in use
- In event of air embolism, put patient on TRENDELENBURG position, administer high flow O2, code blue when necessary
(Dislodgement/migration of catheter - Central Venous Catheter Complications) Assessment
- Measure and document CVC exposed length
- Assess that CVC dressing is intact
- Assess if patient is at risk for pulling out likes
- Observe for signs of migration/dislodgement: pain, arrythmias, edema, coiling under skin
(Dislodgement/migration of catheter - Central Venous Catheter Complications) Prevention/Nursing Intervention
- Avoid pulling or manipulating catheter
- Restless patient: chemical or physical restraints when necessary
- Do not re-advance if migrated externally
- Escalate if migrated internally
Central Venous Pressure Monitoring is done by measuring pressure in the ____ to estimate ___
Vena Cava
To estimate pre-load and right atrial pressure
*latest evidence says not accurate
End tidal capnography clinical application
Verify ETT placement
Adequacy of ventilation
Continuous monitoring of ETT/Trachy tube location during transport
Effectiveness of resuscitation & prognosis during
cardiac arrest
ROSC indicator during chest compressions
Titrating ETCO2 in patients with high ICP
Prognostication in trauma
What is the Richmond Agitation-Sedation Scale used to assess?
Assess lvl of alertness & agitated behaviour in ICU pts
Scale for Richmond Agitation (Hint: -5 to 4)
COMA
-5 (Unarousable) - no response to voice or physical stimulation
STUPOR
-4 (Deep sedation) - no response to voice, responds to physical stimulation
DELIRIUM
-3 (Moderate sedation) - respond to voice, nil eye contact
-2 (light sedation) - respond to voice, eye contact < 10 sec
-1 (drowsy) - respond to voice, eye contact > 10 sec
0 (alert & calm)
1 (restless) - anxious, nil aggressive movements
2 (agitated) - frequent, non-purposeful movement
**3 (very agitated) - pull/remove tubes & catheters, aggressive
4 (combative) - overtly combative, violent, danger`
Acute confusional state is characterised by:
Altered mental status
inability to focus
disorganised thinking
3 types of ICU delirium
Hypoactive
Hyperactive
Mixed
Assess safety for extubation
- Stable medical condition: root cause solved? V/S stable?
- Successful SAT (spontaneous awakening trials) and SBT (spon breathing trials): SBT –> 30 min then ABG thereafter
- Able to protect airway
- Risk for post-extubation stridor: risk factors include prolonged/traumatic intubation, large ETT, low GCS
- Potential difficulty w reintubation: Mallampati score, skilled operator
- Timing to extubate: Manpower availability (day vs night)
Equipment for extubation
Oral & ETT suction apparatus
10ml syringe
Continuous V/S monitoring
Post extubation oxygen device
How to prepare patient for extubation?
Position: 30-45 deg if no contraindication
Explain procedure to pt
Standby for intubation incl manpower for HIGH RISK pts
