CRITICAL CARE: GENERAL OVERVIEW Flashcards
Definition of Critical Care Nursing:
•Definition of Critical Care Nursing: Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems. A critical care nurse is a licensed professional nurse who is responsible for ensuring that acutely and critically ill patients and their families receive optimal care.
Definition of a Critically Ill Patient:
•Definition of a Critically Ill Patient: Critically ill patients are defined as those patients who are at high risk for actual or potential life-threatening health problems. The more critically ill the patient is, the more likely he or she is to be **highly vulnerable, unstable and complex, thereby requiring intense and vigilant nursing care. **
ROLE of the Critical Care Nurse
- Assessment
- Continuous electronic monitoring (7)
- Titration of
- Communication
- Documentation
- •1:1 assessment
- •Complex to focus
- •Continuous electronic monitoring
- –ECG
- –Respiratory Rate
- –BP: NIBP or Arterial
- –Oxygenation: SpO2, SvO2
- –Temperature
- –Hemodynamic monitoring: PA, IABP
- –ICP monitoring
- •Titration of IV medications
- •Communication
- •Documentation
Critical Nurse Scope of Practice (7)
- •Assessment
- •Diagnosis
- •Outcomes Identification
- •Planning
- •Implementation
- •Evaluation
•Impaired gas exchange
Nursing Interventions
Nursing Interventions
**Altered Respiratory Pattern
Nursing Interventions**
Nursing Interventions
**Impaired circulation
Nursing Interventions**
Nursing Interventions
**Risk for hemodynamic instability
Nursing Interventions**
Nursing Interventions
Risk for infection
Nursing Interventions
Nursing Interventions
**Risk for injury
Nursing Interventions**
Nursing Interventions
Knowledge deficit
Nursing Interventions
Nursing Interventions
**Impaired neuro-sensory function
Nursing Interventions**
Nursing Interventions
Altered nutrition
Nursing Interventions
Nursing Interventions
Altered family processes
Nursing Interventions
Nursing Interventions
Pain
Nursing Interventions
Nursing Interventions
Fluid volume deficit
Nursing Interventions
Nursing Interventions
Fluid volume excess
Nursing Interventions
Nursing Interventions
Altered thermoregulation
Nursing Interventions
Nursing Interventions
What will you do?
5 week old female
CC: N/V/D x 24 hours
B: five weeks normal delivery.
A: pale, good tone, alert, wet diaper, ST at 150, RR 32.
5 Week old:
- Assess
- IV
- Lumbar puncture
What would you do?
56 yo female
CC: change in LOC +N/V in last 4 hours. Sent STAT from CT scan
B: Lung ca
A: somnolent, left side droop, LS course, Tachypnea,
Denies: CP
56 year old no meds why
What would you do?
58 yo male
CC: frank blood in stool, hypotension
B: liver, heart failure, + BMI, HTN, DM, ETOH
A: yellow, somnolent, LS dim, Abdomen distended, firm, Denies N/V/CP. + SOB. Frank blood guiac +,
Radial 2+ B
4+ pitting edema to mid-thigh.
58 vasopressor…fluids?
What would you do?
78 yo female
CC: leg pain
B: COPD, Sleep apnea, obesity. HTN.DM II
A: Bilateral cellulitic legs, rhonchi, Denies N/V/D/CP. + SOB
Pain 6/10
Radial 2+ B
Pedal 0 B
If pt is in shock you can’t give fluid continously
Assessment of Critically Ill Patient
- Status (3)
- Head to toe, ALWAYS…
- Neuro use?
- Cardiac monitoring (6) /rhythm use lead?
- In ICU add ___?___ monitoring
- IV access consider (4)
- Labs? What kind?
- •Stable, Unstable Dieing
- Head to toe (physically all over ! **Turn the patient over **
- •Neuro..neuro..neuro. (GCS)
- •Cardiac monitor: rate, rhythm (lead II), BP, O2 Sat, RR
- –IN ICU add hemodynamic monitoring
- •IV access: how many, what size (or IO or Central Line)
- •Full sets of lab work
- •Heart sounds
- •LS
- •I & O/ hour or more frequently
- •Vital signs…q minute!
- •Document/communicate/assess/document
Nursing Care
Always include (6)
- Airway
- Breathing
- Circulation
- Nursing interventions
- Pain comfort
- Family coping
**Circulation **
3 ways to correct the situation?
- –Fluids
- –Blood
- –Meds
- Neuro Assessment: Use which tool?
- Glasglow coma scale
- Neuro Assessment: Why do the Glasgow Coma Scale?
- Perfect score?
- Less than 8?
- What are you using to intubate?
- GLASGOW HELPS TO DETERMINE HOW AIRWAY SHOULD BE MANAGED
- 15
- Less than 8 intubate
- Endotracheal intubation
ABCDEFGHI Trauma Assessment
The ABCDEFGHI mnemonic is used for a quick assessment of trauma patients. This is especially useful for emergency cases.
A Airway
B Breathing
C Circulation
D Disability (neurologic status)
E Expose (remove clothing, keep the patient warm)
F Full set of vital signs
G Give comfort measures
H History/Head-to-Toe assessment
I Inspect posterior surfaces
Altered Breathing Patterns: Terminology
- “DOE”
- **Kussmaul’s **
- Hyperventiliation caused by?
- Hypoventiliation caused by ?
- •Tachypnea -
- •Bradypnea –
- •Apnea
- •Dyspnea -
- •Hyperventilation -
- •Hypoventilation –
- •Kussmaul’s -
- •Cheyne-stokes
- •Orthopnea
- •“DOE”: dyspnea on exertion
- •“SOB” Short of breath
Biots Respiration
Regular breathing pattern followed by apena 10 seconds to 1 minute
Oxygen (1st drug of choice)
- Assess: (3)
- Interventions:
- –Nasal cannual ___ to ___ L/mim (at _?__ add H20)
- –NRB: at least ___ to ___ L/min FLUSH, make sure to ___?___
- –Cpap
- –BiPap
- –Intubation
- •Sedation and BVM
- •Ventilator
- color, 02Sat on RA, ABG’s
- Nasal cannual ___ to ___ L/mim (at 4 liters add H20)
–NRB: at least ___ to ___ L/min FLUSH, make sure to inflate the bag
–Cpap
–BiPap - intubation
- Sedation and BVM
