ICU Flashcards
what is critical care nursing?
field of nursing which focuses on the care of critically ill or unstable patients
what patients often need critical care?
those with life threatening or potentially life threatening problems
why is intense and often constant monitoring of the critical patient needed?
their condition can change on a moment to moment / hour to hour basis
what is a vital skill of a critical care nurse?
able to respond rapidly to an emergency or crisis situation
what patients need critical care nursing?
cardiovascularly unstable respiratory distress neurological disease multiple trauma systemic disease extensive wounds or burns electrolyte imbalances patients with sepsis or systemic inflammatory response syndrome neonates / adolecents
what is triage?
assessment of patient to see if they are stable or unstable and decide order of treatment
when is triage especially useful?
when multiple patients arrive in a short time frame
what is the main question that needs to be answered during veterinary triage?
can the patient be left with the owner or do they need immediate veterinary intervention
what is involved in triage?
quick physical assessment of the 3 major body systems
what are the 3 major body systems assessed in triage?
CVS
respiratory
neuro
how long should the triage primary survey take?
no longer than 2 minutes
what happens if the patient fails any of the 3 major body system assessments in triage?
they have failed triage, are not stable and require immediate intervention
where is triage usually undertaken?
reception area / car park with the owner present
what should you do when arriving to a patient for triage?
Introduce yourself to client: Your name, your role and a brief summary of what
you are intending to do next
what question must you ask before approaching a patient to be triaged?
Ask the client if the patient is friendly – your safety is still paramount in these situations
when can a triaged patient stay with their owner?
if stable and passed triage and owner is happy to be left with them
what should happen if a patient is unstable / has not passed triage?
Immediately take patient from the owner for emergency treatment
what questions should be asked during triage assessment?
Is the patient tachycardic/bradycardic?
What is the pulse quality like?
Is the patient tachypnoeic/dyspnoeic?
Does the patient have respiratory distress or visible effort when breathing?
Is there excessive bleeding?
Is the patient severely painful?
Is the patient bright & alert or dull/obtunded/collapsed?
Is the patient ambulatory?
Is the patient displaying seizure activity?
What is the colour of the patient’s mucous membranes and is this abnormal e.g. white, red, grey or brown?
What is the patient’s capillary refill time and is this within normal range?
what must be communicated to the owner during triage?
Explain to the owner what you have found and why you are concerned
Ask their permission to take the patient for further assessment and/or treatment
Explain someone will be back shortly to give them an update and collect a full history
Remember – this can be a very distressing situation for the client!
how may communication with client differ in a real emergency?
very quick explanation and then take patient!
what should you do if you triage a patient and you are unsure of their triage status?
take the patient to ask for a second opinion, it is better to be overcautious, than potentially leave an unstable patient without treatment!
in the critical patient what should monitoring be tailored to?
the individual
what is useful for monitoring the critical patient?
monitoring equipments
what is even more key than monitoring equipment when monitoring the critical patient?
good regular physical assessment and eye for observation
why should you never 100% rely on monitoring equipment?
equipment can fail
what must be recognised during monitoring?
trends - deterioration or improvement
what critical patients are likely to need constant monitoring?
critical patients and those likely to deteriorate
what critical patients are likely to need monitoring every 15-30 mins?
GA recovery, starting blood transfusion
what critical patients are likely to need monitoring every 1-2 hours?
hypoglycaemic patients, monitoring RR, needing medication
what critical patients are likely to need monitoring every 4-6 hours?
stable patients but clinical status may deteriorate e.g. coagulopathies, cardiac disease
what are the 3 body systems that need to be monitored and assessed frequently?
cardiovascular
respiratory
neurological
how can the CVS be monitored?
PR and quality HR BP MM CRT ECG auscultation
what are the best pulses to assess PR and quality in dogs?
femoral
dorsal pedal
what are the best pulses to assess PR and quality in cats?
femoral
dorsal pedal often hard to feel
when assessing PR and quality what are you looking for?
PR within normal limits
ascertain pulse quality
are there pulse defecits
how can you assess for pulse deficits?
auscultate and feel pulse at the same time
what is a regular pulse with no deficits?
PR matches HR - one pulse for every heart beat
what do pulse deficits indicate?
arrhythmia
what should you do if there is an irregular pulse?
attach ECG
auscultate
paper ECG trace
what are the 3 main types of abnormal pulse quality?
weak / thready
bounding (strong and longer duration)
snappy (strong and shorter duration)
what do weak/thready pulses indicate?
indicative of decreased systolic BP e.g. hypovolaemia/hypoperfusion
what do bounding pulses indicate?
sepsis
what do snappy pulses indicate?
anaemia
what is the normal HR in small breed dogs?
100-140 bpm
what is the normal HR in large breed dogs?
60-100 BPM
what is classed as tachycardia in dogs?
> 140 bpm
what is normal HR in cats?
140-180 bpm
what is classed as tachycardia in cats?
> 180-200bpm
what is classed as bradycardia in dogs?
<60 bpm
what is classed as bradycardia in cats?
<120 bpm
what may affect HR?
pain
stress
drugs
can increase or decrease HR
what is normal blood pressure for dogs?
systolic: 110-160
diastolic: 55-110
what is normal BP for cats?
systolic: 120-170
diastolic: 70-120
what is normal MAP for dogs?
100 mmHg
what is normal MAP for cats?
135 mmHg
what is the acceptable range of MAP for cats and dogs?
60-120 mmHg
what systolic BP is classed as hypotension?
<100 mmHg
what MAP is classed as hypotesion?
<60 mmHg
how can hypotension be treated?
fluid bolus
vasopressors
what do vaspopressors do?
cause vasoconstriction
what systolic BP is classed as hypertension?
> 170-200 mmHg
what MAP is classed as hypertension?
> 120 mmHg
how should hypertension be treated?
Antihypertensive drugs e.g. amlodipine
Investigate and treat underlying cause
what are the non-invasive methods of BP reading?
doppler
oscillometric
how does a doppler measure BP?
Uses sound waves to detect arterial blood flow as an audible signal
how does oscillometric BP read BP?
Detects oscillations as blood flow returns to occluded artery
where should blood pressure be read?
calm, quiet environment
where patient has adjusted to surroundings wherever possible
what position should BP be read in?
lateral recumbancy
what should the cuff be level with when measuring BP?
R atrium
in what animals is it more crucial that the BP cuff is level with the R atrium?
large breed dogs
how many BP readings should be taken?
3-5 and then use average
over a period of time
what is the correct BP cuff size?
40% of leg circumferance
what is the effect of a BP cuff that is too large?
falsely low readings
what is the effect of a BP cuff that is too small?
falsely high readings
what is the gold standard method for BP monitoring?
invasive - measured directly from the artery
what is required for invasive BP monitoring?
arterial catheter placement
transducer
multiparameter monitor
what BP measurements can be shown through invasive BP monitoring?
systolic
diastolic
mean
is invasive BP measurement continuous?
yes - produces a wave-form
describe normal MM
pale pink (presence of RBC’s in capillary beds of MM’s)
what is suggested by red/ hyperaemic MM?
may suggest sepsis
what is suggested by bright/cherry red MM?
carbon monoxide toxicity
what is indicated by very pale / white MM?
anaemia or shock
what do brown MM indicate?
indicative of paracetamol (acetaminophen) toxicity
what is indicated by cyanotic MM?
hypoxia / hypoxaemia
what do icteric / jaundiced MM indicate?
suggests liver disease or haemolysis
what does petechiation on MM suggest?
coagulopathy
when are tachy (dry) MM’s observed?
dehydrated patients
define CRT
the amount of time it takes colour (i.e. blood) to return to the capillary bed of the membrane, after digital pressure has been applied
what is CRT an indicator of?
peripheral perfusion
what is normal CRT?
1-2 seconds
what is indicated by prolonged CRT?
shock
hypoperfusion
what is prolonged CRT due to?
vasoconstriction
what is classed as a prolonged CRT?
> 2.5-3 seconds
what is indicated by a rapid CRT (<1 second) and red/hyperaemic MM?
sepsis/SIRS
rapid CRT due to vasodilation
what is indicated by a prolonged CRT and pale MM?
vasoconstriction (shock / hypoperfusion)
what is indicated by a normal CRT and pale MM?
anaemia
what is measured by an ECG?
the electrical activity of the heart
what is the most accurate method to interpret ECG?
paper trace
when is an ECG essential?
crash scenario
when should all patients have constant ECG monitoring?
all cardiac patients
those likely to have arrhythmias (e.g. GDV and sepsis)
what is enabled by an ECG trace?
distance monitoring
how can the heart be assessed?
auscultation and listen for abnormalities
what should you be listening for or heart auscultation?
any abnormalities (e.g. murmurs, gallop rhythm) pulse deficits
what areas of the respiratory system can be monitored?
RR resp effort lung auscultation pulse ox capnography ABG O2 therapy
what is normal RR in dogs?
10-30 brpm
what is normal RR in cats?
20-30 brpm
what is bradypnoea?
<15 brpm
what are the causes of bradypnoea?
srugs
hypocapnia
CNS disease (affected resp centre)
hypothermia
what breaths per min is classed as tachypnoea?
45-50 brpm
what are the causes of tachypnoea?
hypoxia / hypoxaemia hypercapnia pain hyperthermia pyrexia stress compensation for metabolic acidosis
what is apnoea?
Absence of any ventilatory effort (patient has stopped breathing)
what are the causes of apnoea?
Respiratory or cardiac arrest
Drug overdose
Neurological complications e.g. increased ICP
what is normal respiratory effort?
Gentle chest movements, minimal abdominal movement
what is dyspnoea?
difficulty/laboured breathing
what indicates dyspnoea?
Increased chest and abdominal muscle movement Postural changes (orthopnoea) e.g. extension of head and neck, abduction of elbows, nostril flaring on inspiration Open-mouth breathing
what are the causes of dyspnoea?
Upper airway obstruction and flail chest
Pleural space disease e.g. pleural effusion, pneumothorax and diaphragmatic rupture
Pulmonary parenchymal disease e.g. pulmonary contusions, pulmonary oedema and pneumonia
Upper airway disease e.g. BOAS, laryngeal paralysis
what may be seen with upper airway obstruction and flail chest?
paradoxical breathing pattern (‘see-saw’ effect of thorax
and abdomen)
how is decreased respiratory effort shown?
Reduced chest and abdominal muscle movement
what can cause decreased respiratory effort?
Head and spinal trauma/injury
Tetanus
End stage respiratory fatigue/failure - if tachypnoeic for a long time
what should be done when assessing the respiratory system first?
listen to patient’s breathing from a distance and observe the breathing pattern
what should you observe about breathing sounds?
Is there noise on inspiration, expiration or both?
Stridor (dry noise, e.g. laryngeal paralysis)
Stertor (wet noise/snore e.g. BOAS)
how should you auscultate the thorax to listen for lung sounds?
Divide hemi-thorax (left and right lungs) into dorsal, middle and ventral
lung fields
Auscultate each lung field cranial to caudal
Compare adjacent lung fields and left/right lungs
what causes decreased/absent lung sounds dorsally?
pneumothorax
what causes decreased/absent lung sounds ventrally?
pleural effusion
what is decreased/absent lung sounds accompanied by?
rapid, shallow breathing pattern (due to limited space for lungs to expand adequately)
what sounds may be heard if there is diaphragmatic rupture?
Borborygmi (gut sounds)
what are crackles/wheezes on lung auscultation indicative of?
bronchopulmonary disease e.g. pulmonary oedema, pulmonary contusions, damage/disease of lung parenchyma e.g. pneumonia
what is measured by pulse ox?
Measures oxygenation of blood (% of oxygen bound to haemoglobin in arterial blood)
what is assessed by pulse ox?
Assesses patient’s oxygenation levels
what is the benefit of pulse ox?
Non-invasive and provides continuous information
what is the disadvantage of pulse ox?
Does not measure tissue perfusion or ventilation
what is normal SpO2?
> 95%
where can the pulse ox reader be placed?
Tongue, lip, ear, inguinal fold, prepuce or vulva
Pigmentation can affect reading so avoid these areas
Rectal probes also available
what is measured by capnography?
measures amount of CO2 present in expired gas
what is normal EtCO2?
35-45 mmHg
what EtCO2 indicates hypercapnia?
> 50 mmHg
what EtCO2 indicates hypocapnia?
<30 mmHg
why is EtCO2 an indirect measurement of ventilation?
EtCO2 value is approx 1-4 mmHg less than PaCO2
what may affect measurement of capnography / capnography trace?
System leaks Endotracheal tube (ET tube) kink Sensor obstruction Airway obstructions e.g. mucous secretions, regurgitation Apnoea – aids early detection of cardiac arrest
what does the partial pressure of oxygen measure?
amount of O2 dissolved in arterial blood
what does the partial pressure of CO2 measure?
amount of CO2 dissolved in arterial blood
what is measured by PaO2?
the patient’s ability to oxygenate their blood
what is the normal range of PaO2?
80-100 mmHg
what is indicated by PaO2 of 70-80 mmHg?
mildly hypoxaemic, may require oxygen supplementation
what is indicated by PaO2 of <60 mmHg?
considered severely hypoxaemic, oxygen therapy required
what is measured by PaCO2?
the patient’s ability to ventilate and perform gas exchange in the alveoli
what is the normal range of PaCO2?
35-45 mmHg
what does PaCO2 of <35mmHg indicate?
hyperventilation (hypocapnia)
what does PaCO2 of >45mmHg indicate?
hypoventilation (hypercapnia)
where may ABG samples be gained from?
dorsal pedal artery
what are the main considerations when giving oxygen therapy?
Important to minimise patient stress
Hands off approach
Minimal handling/restraint
Patient is very fragile – can decompensate rapidly
Provide oxygen in method least stressful to patient
Allow 15-30 minutes of oxygen/in oxygen cage before further examination (unless obviously obstructed)
Equipment prepared for emergency intubation
how long should a patient receive oxygen therapy before they are examined further (unless obvious obstruction)?
Allow 15-30 minutes of oxygen/in oxygen cage
what are the non-invasive methods of oxygen provision?
Flow-by oxygen e.g. mask, tubing held near patient’s nose/mouth
Oxygen cage
Nasal prongs
what are the invasive methods of oxygen provision?
Nasal catheters
Trans-tracheal
Endotracheal(intubation)
Ventilation either manual (IPPV) via personnel or mechanical via machine
why are nasal catheters useful?
harder for patient to remove
how can the neurological system of a patient be assessed?
mentation cranial nerve function MGCS raised ICP seizures
what are the main levels of mentation?
normal obtunded stuperous comatose hyper-excitability
describe normal mentation
Alert, responds appropriately to stimuli
describe obtunded mentation
Reduced alertness/consciousness, easily roused with non-noxious stimuli
describe stuperous mentation
Unconscious, only rousable with noxious stimuli
describe comatose mentation
Unconscious, no response to any stimuli, including noxious stimuli
describe hyper-excitability
excessive reaction to stimuli
what are the potential causes of reduced mentation?
Shock/hypoperfusion
Hypoxaemia e.g. severe anaemia
Primary neurological disease
what assessment can be used to check cranial nerve function?
pupillary light reflex pupil size and symmetry oculocephalic reflexes menace reflexes nystagmus strabismus
what is the PLR ?
Pupil response to light e.g. pen torch
what is the correct PLR?
pupils should respond to light bilaterally,
rapidly and consensually
what should pupils be like?
Pupils should be of an equal size & shape
what is anisocria?
pupils are different sizes
why is miosis?
constricted pupils
what is mydriasis?
dilated pupils
how is oculocephalic reflex checked?
response of eyes checked when head moved from side to side to check for physiological nystagmus
what is the menace reflex?
Reflex blinking that occurs in response to the rapid approach of an object e.g. hand
what is nystagmus?
Eyes make repetitive, uncontrolled movements without movement of the head (not physiological)
May be horizontal, vertical or rotational
what is strabismus?
One or both eyes deviate from normal position
what can indicated raised ICP?
Absent PLRs or changes in pupil size
what can cause raised ICP?
trauma
intra-cranial lesions (e.g. tumor or inflammation)
what are the 3 sections on the MGCS?
motor ability
brain stem reflexes
level of consciousness
what is assessed in the motor activity area of MGCS?
gait and ambulation
what is assessed in the brain stem reflexes area of MGCS?
PLRs
oculocephalic reflexes
pupil size
what is assessed in the level of consciousness area of MGCS?
response to visual, auditory and noxious stimuli
what is the total MGCS score out of?
18
when should clinicians be notified about altered MGCS?
if score has deteriorated by 2 or more since last check as may indicate raised ICP
what is the cushing’s reflex?
classic response to increased ICP with marked hypertension and reflex bradycardia
what is required for a patient with the Cushing’s reflex?
emergency treatment
May require osmotic diuretics to reduce brain swelling/oedema e.g. Mannitol, hypertonic saline
how should patients at risk of raised ICP be monitored?
Assess MGCS, HR, BP, RR q1 – 6hrs, depending on patient stability
what patients are at risk of raised ICP?
head trauma, seizures e.g. status epilepticus and meningoencephalitis patients
what position should patients at risk of raised ICP be placed in?
elevate head and thorax upwards by 30-40 degrees
sternal recumbancy to aid respiratory ventilation
why is elevation head and thorax upwards by 30-40 degrees in patients at risk of raised ICP helpful?
decreases pressure on brain due to increased venous drainage
how can you avoid inadvertently increasing ICP in at risk patients?
No jugular samples
Avoid stimulation to sneeze e.g. intranasal catheters or nasal prongs
Avoid stimulation to gag/vomit e.g. intubating a light patient, morphine
what elevated parameter may seizing patients develop?
hyperthermia - may need active cooling
what should be in and around the kennel of a patient who may potentially seizure?
Seizure plan on kennel door
Seizure medications easily accessible
Padded kennel
what should be provided to all patients during / after seizures?
flow by oxygen
when should the thorax and head of seizing patients be elevated?
once safe to do so
what personal safety concerns are there with a seizing patient?
take care not to get bitten during seizure
what should be noted about a seizure when it occurs?
Length of seizure (e.g. drug intervention after seizure is > 2 minutes long)
whether seizure is artial e.g. facial twitching, jaw chomping, fly catching etc or full e.g. tonic clonic seizure
what should patients with lesions of cervical origin be monitored for?
Closely monitor respiratory function
what are the main considerations when dealing with spinal trauma patients?
spinal board for transport and movement of potentially unstable spines
keep flat
minimise movement
what are the main considerations when dealing with patients with decreased consciousness?
Monitor gag reflex, monitor for regurgitation, may require airway protection e.g. intubation
Physiotherapy and hygiene e.g. eye and oral care
what are the main areas found in a critical care ward?
Triage station – secondary assessment/emergency treatment area High dependency (critical) patient area Emergency crash station Feline friendly area Nursing station Laboratory area
what is key about the triage area of ICU?
must be set and ready at all times
why may an ultrasound machine be useful in triage?
free fluid checks of thorax or abdomen
what level of nursing do patients receive in the high dependency area of ICU?
1:1 constant monitoring
what is key about the high dependency area?
access to patient from all sides at all times
what is key about the crash station?
designated table is kept clear at all times
how often should stock in crash trolley be checked?
once a month but must be fully restocked and checked straight after each use
what is contained within the crash trolley?
only necessary equipment / drugs
what equipment is needed on the crash trolley?
Varity of ET tube sizes Laryngoscope Tube tie/cuff inflator Intubeze for cats Suction equipment IV consumables Pre-drawn saline for flush Emergency chest drain equipment Intraosseous needles and equipment ECG pads Ambu-bags for ventilation Defibrillator and gel Essential drugs: adrenaline, atropine, reversal agents Easy to see drug dosage chart
what are the drug doses given in on a crash trolley chart?
ml so can be dosed quickly
what is different about the feline friendly ICU ward?
glass doors - easy to see into but reduce noise
cover on lower half of door to prevent cats seeing passing dogs
seperate oxygen cages
what are the key features of the ICU nursing station?
able to observe entire room
computer access
list of contact numbers easy to access
patient records to hand
where is the lab area situated in ICU?
within the emergency ward area
what is the purpose of a lab area in ICU?
Quick diagnostics for emergency patients
Out of hour samples (lab closed)
what is found in the lab area of ICU?
Blood gas/electrolyte machine centrifuge Diff-Quik stain haematology machine biochemistry machine coagulation times microscope SNAP tests
what are the tests involved in the minimum database?
Packed cell volume (PCV)
total solids (TS)
blood gas analysis (acid base, electrolytes, lactate, oxygenation and ventilation)
blood glucose
what tests are involved in the extended database?
Biochemistry e.g. ALT, ALKP, BUN, CREA
Haematology e.g. complete blood cell count, blood smear
Urinalysis e.g. sediment analysis, dipstick and urine specific gravity (USG)
Coagulation profile e.g. APTT, PT
Blood typing
Blood cross matching
SNAP tests e.g. 4DX, Parvovirus, Angiostrongylus
what is tested by ALT and ALKP?
liver function
what is tested by BUN and CREA?
kidney functions
what should patient accommodation be tailored to?
patients needs or requirements
what are the main kennel types available in ICU?
Kennel size - small, medium and large Walk in kennels Top or bottom kennels Oxygen kennels Incubator Cot/trolley for critical patients
what are the main considerations for where to house patients in ICU?
Access for nursing care and observation Proximity of oxygen and electricity Breed/temperament Patient is easily visible Do we need to barrier nurse? Is the patient recumbent?
what is needed within the kennel to ensure patient comfort?
Comfortable bedding
Inco pads under bedding
Positioning aids
Elevated water/feeding bowls e.g. Great Dane
what comfortable bedding can be offered to ICU patients?
Vetbeds, duvets, orthomats, non-slip mats, blankets
Appropriate to breed/species/problem
why should inco pads be placed between layers of bedding?
prevent urine scaulding
what positioning aids may be used for ICU patients?
Pillows, foam wedges, sandbags, towels
what specific things may be required for the kennels of cats in ICU?
hiding areas/bed boxes, consider type of cat litter (some from home)
do all patients have to be housed in a kennel?
if especially stressed they can be left supervised outside of a kennel
when are incubators usually used on ICU?
for neonates
what should the environment of ICU be tailored to?
patients needs
what are the main considerations regarding the ICU environment?
Calm, quiet +/- dim lighting
Reduced people traffic: infection and noise control
Warning signs on doors
Separate kennel area for cats
Keep clean and tidy
Consumables easily available and stocked up
Quick and easy access to monitoring equipment
where should patients hospital sheet be kept?
on the fornt of the kennel
what information should be placed on the ICU hospital sheet?
Patient details Owner details Date Problem list and notify if list Tubes, drains and IV lines IVFT and medications due Clinical notes Admit weight Daily record of weight Daily record of RER Record of food intake Clinician’s notes Clinician in charge and contact details Patient temperament
what are the key nursing considerations for ICU patients?
infection control hygiene body temperature lines, tubes and drains physio nutrition pain and stress fluid balance TLC
what are the key steps of infection control in ICU?
Hand hygiene – washing before and after each patient
Wiping equipment after each use
Appropriate use of gloves
Prevent hospital acquired infections (HAI’s)
what is required for barrier nursing?
Personal protective equipment (PPE) e.g. gloves, apron, +/- mask/shoe covers
which patients should be barrier nursed?
Any patient with wounds/potential infectious disease/compromised immune system
what patients is provision of hygiene care essential for?
recumbent patietns
what is involved in hygiene care of recumbent patients?
Providing frequent eye lubrication as required
Providing oral hygiene
Monitor urine or faecal continence and prevent urine/faecal scalding
Treatment of urine/faecal scalding
what barrier products may be used in recumbent patients to prevent urine or faecal scalding?
Sudocrem, Vaseline, Cavilon spray .
how is oral hygiene provided to recumbent patients?
Clean mouth with solution appropriate for use on MM’s
how is urine/fecal scalding treated?
Flamazine, Isaderm cream
what may need to have it’s size monitored in the recumbent patient?
bladder
how can bladder size be monitored?
palpation or ultrasound measurement
how can the bladder be emptied?
expression
catheterisation
why are vet beds necessary in recumbent patients?
wick away urine from patient
what should you do if the patient is soiled?
clean with animal friendly shampoo to reduce the risk of infection and scalding
what may be placed to keep the patient a bit cleaner if faecal incontinence/diarrhoea present?
tail bandage
how can hypothermia be treated?
Incubator Bubble wrap Heat mats (NOT directly under patient!) Hot hands Bair hugger Fleece blankets/vet beds Warmed IV fluids
when should patients be actively cooled?
> 40 degrees C unless pyrexic
why should pyrexic patients not be cooled?
adaptive response to infection so should not be reversed
what patients are at risk of hypeethermia?
BOAS
laryngeal paralysis
seizure
how can hyperthermia be treated?
an/air conditioning Ice under bedding Cooling mats Cold damp bedding/towels – NOT placed over the top of a patient Tepid water bath NOT very cold water oxygen flow-by sedation in some cases
how often should the temperature of the hyperthermic patient be checked?
q1 min
when should active cooling end?
39 degrees C to prevent hypothermia
when should lines, tubes and drains be checked?
minimum twice daily
what is needed for lines, drains and tubes to ensure they are managed the same by all staff?
SOP
when should lines, tubes and drains be removed?
as soon as no longer required
how should lines, tubes and drains be handled?
aseptically to reduce infection risk
what should be done with all lines, tubes and drains?
should be labelled clearly to prevent incorrect administration through them
what should be recorded from drain output?
amount produced
type
colour
what should be calculated from line, tube or drain fluid output?
ml/hr which will enable fluid calcs
why must lines/tubes be clearly labelled?
to avoid mistakes with administration
what are the general aims of physio?
Decrease chance of complications e.g. recumbent patients Improve circulation Allow muscle/tendon relaxation Aid pain management Reduce inflammation Promote recovery
what are the indications for physio?
Pressure sores/decubitus ulcers Muscle contraction/spasm Build-up of pulmonary secretions Muscular weakness/atrophy Joint stiffness Limb swelling Pain Depression/boredom/stress
what patients are contraindicated for physio?
Unstable critical patients
Unstable limb/spinal fractures or spinal injuries
Head trauma
Blood disorders e.g. thrombocytopenia (bleeding risk)
Very stressed or painful patients – patient must be appropriately analgised before attempting physiotherapy
what are the main types of physio?
positioning chest care PROM swelling management pain relief progressive exercise
what action is involved in positioning physio?
Regular re-positioning: alternate R/L/Sternal q2-4hr
Limb elevation
Calm gentle handling
what action is involved in chest care physio?
Gentle exercise
Positioning
Massage and coupage
what action is involved in PROM physio?
Passive movements
Stretches
Active exercise
what is involved in swelling management physio?
Effleurage
Elevation of limbs above heart level
Cryotherapy
what is involved in pain relief physio?
Neutral positioning and regular repositioning
Passive movements
Gentle massage
what is involved in progressive exercise physio?
Assisted or active standing and walking
what is the benefit of positioning change physio?
improved respiratory function
Prevent pressure sores
Prevent lung atelectasis (especially if unable to move)
what is the benefit of chest care physio?
Maintenance of bronchial hygiene Loosening secretions Re-expansion of atelectatic lung Improved oxygenation Reduced risk of aspiration
what is the benefit of PROM physio?
Maintenance of joint and muscle range
Help with muscle atrophy
what is the benefit of swelling management physio?
Quicker recovery time
Reduce limb oedema
what is the benefit of pain relief physio?
Greater comfort
Quicker recovery
Easier mobilisation
what is the benefit of progressive exercise physio?
Reduced loss of strength and range of motion
Loosening and elimination of secretions from airways
Re-expansion of atelectatic lung
what is required by enterocytes in GI tract?
direct supply (oral ingestion) of nutrients
what happens to enterocytes if there is not nutrients for >3 days?
cells begin to die
how long without nutrition before enterocytes start to die?
> 3 days
what is the issue created by dying enterocytes?
weakness in GI tract barrier
what can a weakness in the GI tract barrier due to enterocyte death lead to?
Increased intestinal permeability Bacteria and endotoxins can cross barrier and enter systemic circulation (translocation) Impaired immune functions of GIT (largest immune organ in body; contains approx. 50% lymphoid cells in body)
what is translocation?
Bacteria and endotoxins can cross GI tract barrier and enter
systemic circulation leading to sepsis
what is the nutrition aim for critical patients?
provide early entral nutrition as soon as possible
when should nutrition of the critical patient begin?
as soon as possible once patient is adequately stabilised from acute conditions or surgery
Patient may have already been anorexic for many days prior to hospitalisation
what should be calculated to aid nutrition?
resting energy requirement (RER) with a current weight
how can critical patients be encouraged to eat?
Tempt with tasty foods/warming food, hand feeding
Appetite stimulants e.g. mirtazapine
Ensure water needs are met (50ml/kg/day) via oral or IVFT methods
what should be done if the critical patient is unable to eat orally?
consider early placement of enteral feeding tube
what can be caused by re-feeding syndrome?
severe electrolyte imbalance (hypokalaemia?)
how can re-feeding syndrome be avoided?
slow reintroduction of food (e.g. 1/3 RER day 1, 2/3 day 2 etc)
what are the main types of enteral feeding tubes?
Naso-gastric/naso-oesophageal (N-G/N-O) tube Oesophagostomy (O) tube Percutaneous endoscopic gastrostomy (PEG) tube Jejunostomy (J) tube
what does enteral feeding tube placement depend on?
patients issues and co-morbidites
least invasive is first choice
what must you do with an enteral feeding tube before each feed?
check tube is in correct location with sterile water
how often should the insertion site of a feeding tube be checked and the site be cleaned?
BID
what should the insertion site of the feeding tube be cleaned with?
dilute povidone iodine suitable for mucous membranes
what should the feeding tube insertion site be monitored for?
redness, swelling or discharge
how should patients be positioned for feeding through an enteral feeding tube?
sternal/elevate thorax to prevent regurgitation and aspiration
how long must PEG or J-tubes be lift in situ for?
a minimum of 10-14 days after placement
why must PEG/J-tubes be left in situ for a minimum of 10-14 days after placement?
to allow adhesions to form to reduce the risk of peritonitis upon removal
what must be fed through a J-tube?
CRI of specific jejunal diet only
what is parenteral nutrition?
Nutrients provided directly into patient’s blood stream, avoiding GIT
how is parenteral nutrition delivered?
Delivered as a constant rate infusion (CRI)
what are the downsides of parenteral nutrition?
Less balanced nutrition than enteral feeding
Much more expensive for client
when is parenteral nutrition considered?
when enteral feeding is not an option
when may enteral feeding not be an option?
Non-functioning GIT; severe neurological deficits; unconscious patients
what are the 2 types of parenteral nutrition?
total parenteral nutrition (TPN)
partial parenteral nutrition (PPN)
what happens during TPN?
all nutrients given parenterally
how must TPN be given?
via central line/peripherally inserted central catheter (PICC line)
why must TPN be given via central line/peripherally inserted central catheter (PICC line)?
high osmolality that can damage peripheral vessels
what is involved in PPN?
40-70% of nutrients given parenterally
how can PPN be given?
via central or peripheral route
what are the main considerations when giving parenteral nutrition?
Strict aseptic technique - Can cause sepsis as breeding ground for bacteria
TPN NOT peripherally - Can cause thrombophlebitis
New bag and giving set every 24 hours
how often must the parenteral feeding bag and giving set be changed?
New bag and giving set every 24 hours
how can cat pain be assessed?
feline GPS
how can dog pain be assessed?
canine GCPS
when should patients pain be assessed?
repeated intervals throughout day
analgesia plan reviewed frequently
how can stress in patients be minimised?
TLC, strengthen nursing/patient bond e.g. affection, grooming
Sedative drugs to allow periods of rest
Take your time/go slow with nervous patients
Reassurance
Feliway cat diffuser
Hiding areas: boxes/blankets over kennel door etc.
what is hypovolaemia?
decreased intravascular blood volume
how can patients compensate for hypovolaemia?
tachycardia and
peripheral vasoconstriction
what fluid boluses can be given to address hypovolaemia?
5-20 ml/kg over 10 -20 min
what should be done after fluid bolus is given?
patient is reassessed
what is dehydration?
excessive loss of total body water
how can dehydration be calculated?
Estimate degree (%) of dehydration e.g. skin tent, checking MM’s if
tacky
PCV/TS
can patients be both dehydrated and hypovolaemic?
yes or one or the other in isolation
when should patients hydration be assessed?
daily
what should the fluid therapy plan account for?
Ongoing losses e.g. V+/D+
Drains e.g. abdominal/thoracic
maintenance
what is the maintenance fluid rate for dogs and cats?
2 ml/kg/hr
what is the type of fluid therapy decided on based on?
patients clinical condition
when may whole blood or PRBCs be given?
if excessive blood loss during surgery, trauma, severe anaemia etc
what is useful about monitoring patients urine output?
Assess/balance fluid going into patient with fluid coming out (in’s and out’s)
Assesses tissue perfusion
how can urine output be monitored?
Closed system IDUC
Weigh incontinence sheets, bedding and litter
Weigh at least once daily: fluid balance responsible for rapid changes in patient’s weight
what is normal urine output?
1-2 ml/kg/hr
how should indwelling urinary catheters be cared for?
Aseptic handling, wear gloves
Clean twice daily
In plastic bag to keep clean
Ideally kept lower than patient to allow urine to drain via gravity
Do not disconnect closed system e.g. for walks
+/- collar to prevent patient interference
what is involved in providing TLC to patients?
Develop a patient: nurse bond Lights out time Quiet time Grooming/bathing/affection Toys (if appropriate) Time outside the kennel Hand feeding Nursing care plans (NCP) Owner visits
what are the 4 stages of a nursing care plan?
assessment
planning
implementation
evaluation
when are nursing care plans produced?
Incorporated into daily routine
Completed for all critical patients
what are the key benefits of a nursing care plan?
Standardisation of nursing care
ensures patient’s needs met and all areas of nursing are covered
Highlights any problems/potential complications
