ICU Flashcards
nurse to pt ratio ICU
2:1
SDU nurse to pt rati
o
3:1 medsurg nurse to patient ratio
5:1
indicators for the ICU
resp insufficiency
cardio insufficiency
depressed consciousness or coma
(breathing, heart, brain or threat of these things )
Note format in the ICU differs from regular SOAP notes how
- ID
- problem
- background information
- current problems
- physical findings (I and O)
- evaluation of patient by system
systems for evaluation daily in the ICU`
8
respiratory cardiovascular neurological GI and nutrition Hematology Renal Electrolytes
respiratory in the ICU
what do we need to learn with regards to the language
mechanical ventulation
ballon inflates acting like a cork and also for positive pressure ventilation
having this tube protects the airway
when pts are on ventilators you know that, at least with regards to respiration, you are probably okay
3 main types of ventilation modes
refers to the frequency of breaths provided
Assisted-control (AC)
intermitten mandatory ventilation (IMV/SIMV)
spontaneous (spontaneous)
assisted control is used for
pts that are unable to take deep breaths on their own
coma
extreme sedation
fixed rate
can pts initiate breaths on AC
Yes
what to pts need for AC
need to be sedated in order to tolerate
IMV/SIMV
intermitten mandatory ventilation
periodic breaths at a set rate
pt can initiate breaths above that set rate
this is usually much more comfortable for people
pressure support ventilation is used when
pt initiates every breath
but are supported by positive pressure
least invasive and most comfort
used for weaning mechanical ventialtion
how to talk about mechnaical respiration
mode (RR)
TV
FiO2
PEEP
PSV
SIMV 12 (14) 400 50% PEEP=5 PSV=8
12 set breaths pts taking 14
Tidal volume is 400
Fio2 OF 50% Required for saturaton
the positive end expiratory pressure
tidal volume normally
6ml/kg
480ml
what are we worried about what higher tidal volume
associated with barotrauma
with critically ill you usually want low volume ventilation
fraction of oxygen saturation
usually expressed as a percentage
start with 100% when beginning and titrate down
when you are round and presenting and the person requires an fIo2 OF 50% THIS IS A SIGNAL THAT THIS PERSON IS REALLY SICK
PEEP
positive end expiratory pressure-COPD
keeps the alveoli open and is useful in people with “stiff lungs”
need a higher amount
5cm H20 is helpful in promoting oxygen and reducing barotrauma
pressure support (PSV)- is used to
overcomes resistance of the tube
used in iMV and spontaneous ventilation
positive pressure applied with patient-initiated breaths
or else it feels like sucking through a straw
when do you do a tracheostomy
allows you to take the breathing tube out and place a whole for positive pressure ventilation without going through the mouth
prevents errosin of the trachea and bacteria infiltration.
cardiovascular support
what does the heart need in the ICU
a functioning pump
sufficient fluid volume
regulated resistance of the cardiovascular system
when you have pump dysfunction
cardiogenic shock
when you have volume depletion
hypovolemic shock
when you have resistance dysfunction
septic or neruogenic anaphylactic shock
how do you find out what type of shock the patient might be in
hR, rhythm, BP, CP
hx of trauma or illness
EKG echocardiogram
three things we need in managing cariogenic shock
cardiac output
cvp
svr
cariogenic shock
pump problem with reduced co
increased systemic vascular resistance due to hypovolemia
increased central venous pressure
what do you do for cariogenic shock
need to start a inotropic agent
(increased stroke volume leads to increased cardiac output)
dobutamine is one such drug
will relax the SVR and decrease it due to baroreceptor response
does not increase arterial bp so they made need drugs for this as well
hypovolemic shock picture
what does venous pressure look like
decreased CO
decreased central venous pressure
increase systemic vascular resistance
what do you do for the hypovolemic pt
when will loss lead to shock
need fluids
can lose up to 15% of blood volume and compensate
after 30% will go into shock
what is the amount of total body fluid
of a 80 kg man
of a 60 kg woman
what is blood volume
80kg man 48
60kg women 3.6 L
blood volume
- 3L
- 6L
volume replacement looks like
calculate fluid loss
giving 4 times the loss in IV crystallous
percent blood loss times total blood x4
35% x 5.3=1.9 so replace 7.5-8L
target CVP is between
5-10 mm Hg
what does fluid overload look like
12-15 mm Hg
septic or neurogenic shock picture
unable to maintain resistance
increased co
Decreased systemic vascular resistance
how does dopamine help with neurogenic shock at a low dose
low dose (1-5mcg)
increases blood flow to renal, mesenteric, and cerebral regions, by increasing SVR in other regions.
pressures put pts at risks for
ischemic necorosis
hypertensive emergency tx
give anti-hypertensices
drips of nitroprusside, nicardipine, celvidipine, esmolol
use CCB now (pines)
the goal is to get them back on oral medications
Swan Ganz cathter
No longer used
first reason to have person in the ICU
invasive monitor that could detect wedge pressure in the heart
but doesn’t really seem to make a difference in outcome
neurological problem
what exam are we using to evaluate decline
how often do they need to be checked
With neuro issue in ICU, need q1hr neuro checks (can only be done in the ICU with pt:RN ratio 2:1)
glasgow coma score
pupils
reflexes
need to document what is normal for this patient
CPP what is the equation and how do you monitor
Cerebral perfusion pressure (CPP)
so, for critical head injuries, have to monitor/control both intracranial pressure & BP)
MAP-ICP
CPP goal
cerebral profusion goal is around 60 mmHg
gold standard for invasive intracranial pressure monitoring
Ventriculostomy
Licox monitor
inserted like a camino bolt
measures O2 content of blood
considered more useful than camino because it measures direct oxygenation rather than perfusion pressure (which correlates with oxygenation)
goal CPP is often around
60 mm HG
Goal ICP should be
generally less than 22 mm Hg
to maintain CPP we can …
lower ICP (preferable) or raise MAP (last resort)if
if a person is borderline with CPP
if the ICP is within normal limits you know the brain probably has good circulation (unless hypotensive)
a weak point in the cerebral artery
often asymptotic
usually devastating
50% never make it into the hospital
Subarchanoid hemorrhage
management of subarachnoid hemorrhage
critical BP control, neuro checks, seizure and vasospasm prophylaxis
need to be on seizure medication because of lowered threshold
need to repair the aneurysm
repair of the aneurysm
endovascular coiling
catheter is inserted in the groin, snaked up the artery into the brain and placed into the aneurysm
filled with a thread and keeps from rupturing
(does not occur at highland)
what is the F/U care for repair of a aneurysm
very high risk of vasospasm need to stay in the ciu
HHH tx
hypervolemic hypertensive hemodilution
pump them up so there is no chance of vasopsasm (will be experienced as stroke)
nutrition in the ICU
short term
most ICU ptaients are too obtuned to eat and are NPO
use thick NG tube
not dobhoff usually because they can inserted into a lung if not done right
g-tube
long term solution goes to the stomach
many times you need a PEG which is like a G tube
hematology concerns in ICU
when would you consider a transfusion for a pt in the ICU
many pts are ANEMIC
can be consuming RBC
may be malnourished
if HMG falls below 8 can consider a transfusion
can wait till it falls to round 6
need to follow coags (INR) and correct as needed
electrolyte concerns in the ICU
need to follow I and Os very closely
insensate fluid loss is also of concerned
healthy people lose how much water
400 mo H20 from longs and 400mL from the skin
in the ICU you need to follow I and O over multiple days
renal concerns
need to follow urine output
BUN and Cr
these numbers hould not be climbing
three kinds of renal problems and the most common
person in shock will have pre renal
intrinsic damage can occur through durg intake and IV contrast
post obstruction from stones and BPH is uncommon in the ICU but is not unheard of
hypophosphatemia could effect breathing in what ways
makes it harder to wean off ventilator because of the decreased smooth muscle strength
effects the diaphragm
infectious disease concrens in the ICU
we are worried mostly about all the tubes
need to track temp and WBC every day
if they are being treated from infection need to documetn
If pt has a new fever or ↑WBC GET A
panculture
blood
sputum
urine
why are we worried about pneumonia in the icu
Because of the ventilator
need a CXR
prophylaxis for ICU pt
GI/nutrition
hematology-
what is the reason we really need to worry about prophylactic GI nutrition
feed as soon as possible need protein to heal and decreased risk of ulcers
need PPI
stool softener (these pts are constipated–> leads to BO and electrolyte abnormalities)
suppository
hematology prophylaxis
out them on prophylactic heparin or LMWH when pt is hemodynamically stable
which meningitis vaccine do we give
ACYW
teenagers 11-18 yo
(1st dose 11 and second does 16 years old)
anyone younger can get the vaccine if worried about exposure and you would need it for prophylaxis
Men B vaccine
against serogroup B meningitides is given to young children in England
given the low incidence here is is not routine
given to kids going off to collage or kdis going over seen where there are high rates of meningitis
what oxygen saturation is toxic
> 60% for 48 hours can be toxic
at an intermediate dose how dose dopamine work
) stimulates beta receptors in heart, increased cardiac output
At a high dose how does dopamine work
(>10mcg)
stimulates alpha receptors in systemic and pulm circulation, increasing SVR while preserving CO, thus helping to correct hypotension
complications with dopamine
Complications: tachycardia at intermediate doses, ischemic limb necrosis (consider alpha blocker)
goal ICP
generally <22 mm HG
goal MAP
> 8- mm Hg
two ways to maintain CPP
o To maintain CPP, can lower ICP (preferable) or raise MAP (less preferable)
screwed into skull to rest just under dura, provides real time ICP data
o Camino Bolt
measures O2 content of blood, more useful than Camino since it measures direct
o Licox monitor
if a pts with aneurysm ahs a vasospasim requires
Vasospasm requires emergent transluminal balloon angioplasty
will be experienced as a stroke
BIG THREE
kill your pt quickly
respiratory insufficiency,
CV insufficiency
and neuro injury
know all their stats form before
small stuff that can kill your pt slowly
GI/nutrition hematology electrolytes renal, infectious dz
Minimum UOP should be
Minimum UOP should be ≥20ml/hr and BUN/Cr should not be climbing
Pre-renal:
↓blood flow to kidney (hypovolemia, renal artery obstruction
Intrinsic: renal causes
: damage to kidney (drugs, ischemia, infection)
CT
Post-renal:
obstruction of urinary tract (stones, catheter, BPH)
electrolyte imbalance that makes it difficult to wean someone off the ventilator
Hypophosphatemia
d/t decrease in smooth muscle strength including the diaphragm
Hypomagnesemia
what is normal and what kind of problems does it cause
normal range is 1.7-2.3, and low levels <0.7 can cause fatal arrhythmias
Most ICU pts need to be on these meds
stool softeners
PPI- prevent ulcers
Heparin or LMWH
PROPHYLAXIS for DVT
: DVT and PE, every pt should be wearing sequential compression devices on their legs
Every patient should get prophylactic heparin or LMWH when hemodynamically stable.
when would you want to start prophylactic heparin in a pt with a brain bleed
Brain bleed generally wait until 72 hours later but it depends on the brain bleed and how bad it was
overall impressions of the pt in the ICU
Respiratory Cardiovascular Neuro GI/Nutrition Heme FEN/Renal ID Prophylaxis
and monitor medication sedation (propofol or versed) and integumentation
