Gen ICU OSCE

Question 1

RASS

Answer 1

RASS - +4 to -5- 1 = eye contact > 10 secs- 2 = eye contact < 10 secs- 3 = no eye contact

Question 2

CAM-ICU

Answer 2

1 - Is there an acute change in mental status?2 - Test for inattentionThen one of either:3 - Altered consciousness (RASS)4 - Disorganised thinking (questions) and Commands (2 stage)

Question 3

Delirium

Answer 3

Acute change in consciousness and awareness that fluctuates of time - generally in response to physiological consequences of a general medical condition.Thought to be a neurotransmitter imbalance.RFs:1 - Patent factors - Age, co-morbidity, baseline cognitive impairment, ETOH2 - Acute illness factors - High APACHE, sepsis, hypoxia, metabolic derangement3 - Iatrogenic - disturbed sleep/sedative medsReduce risk:ABCDE - Awake and breathing, Choice of sedation, Coordination, Delirium monitoring, Early mobilisation

Question 4

Modified Rankin Score

Answer 4

0 = no symptoms1 = Can carry out all activities with some symptoms2 = Can look after self without assistance but unable to carry out all previous activities3 = Requires some help but can walk unassisted4 = Required assistance for ADLs5 = Requires nursing care or bedridden6 = Death

Question 5

Intubation

Answer 5

Prep-prep-prep!

Prepare Pt - consent, positioning, pre-O2, gastric emptyingPrepare personnel - rolesPrepare environment Prepare drugs Prepare equipment

Question 6

Nutrition

Answer 6

25-30 kcal/kg/day

Protein = 1-2g/kg/dayCarbs = 60% of non-protein caloriesLipids = 40% of non-protein calories

Water = 30mls/kg/dayNa = 1-2mmol/kg/dayK = 1Ca = 0.1Mg = 0.1Phos = 0.4

Question 7

Never Events

Answer 7

Listed by NHS England - wholly preventable by guidance and safety systems. All have potential to cause serious harm or death. All must be investigated a serious incident.Surgical:1 - Wrong site2 - Wrong implant3 - Retained objects

Drugs:1 - Mis-selection of strong K 2 - Wrong route of administration3 - Overdose insulin4 - Overdose of methotrexate5 - Mis-selection of high dose midazolam

General:1 - Fall from windows2 - Chest/neck entrapment in bed3 - ABO incompatible blood4 - NG misplacement5 - Scalding6 - Patient on air when should be oxygen

Question 8

Ethics - capacity

Answer 8

Consent - Should be informed and person has capacityCapacity - two stages 1 - Is there a disorder of brain or mind? Temporary or permanent 2 - Can the patient understand, retain, weigh up and communicate decision?Capacity is assumed in an adultIs decision specific and time specificMental Capacity Act 2005- Assumed capacity- support to make decision- unwise decision allowed- best interests- least restrictive optionAdvanced directive - can only cover refusal of treatment, must be specific, must be in writing, signed and witnessed. Can not refuse actions to maintain comfort.Appoint a lasting power of attorney.Ascertaining persons likely wishesIMCA - substitute for family members, represent patients best interests and help decision making —- used when important decision need to be made without AD/LPA/family , when it is believed a family are not acting in the patients best interests or a conflict between family members.

Question 9

DNACPR

Answer 9

Requested by patient When CPR would not be successfulWhen CPR may work but the harms/burdens of doing so outweigh any possible benefitInform:Patient (unless undue suffering), NOK and other healthcare professionalsDifficult situation when patient/family insist on CPR- Not a withdrawal of support or treatment- PALS support- second opinion- advocate for patient- case conference - ultimately Court of Protection

Question 10

Sedation

Answer 10

Why use sedation:1 - Manage anxiety and agitation2 - Manage pain3 - Allow mechanical ventilation 4 - Control ICP5 - Modify the PTSD response6 - Patient safety

Cont infusion, boluses, enterally Propofol - GABA potentiation (