ICU Flashcards
how to succeed in the ICU
approach the setting systematically
follow lines, leads, and tubes from origins to insertions
know the precautions
when in doubt, ask the ICU nurse!
the nature of the ICU/CCU/Acute Care Setting
patient family staff life-changing injury or illness environmental and psychological effects sleep pattern disturbances ICU/CCU psychosis
environmental stresses of the ICU on the patient
crowding bright lights strong odors endless activity noise touch pain
psychological stresses of the ICU on the patient
diminished dignity and self-esteem powerlessness vulnerability fear anxiety isolation spiritual distress
ICU psychosis is the result of
environmental and psychological stresses
ICU psychosis
delirium usually occurring in the 3rd to 7th day of stay (fatigue, confusions, distraction, anxiety, hallucinations) caused by: pain, drug side effects, ICU/CCU environment itself
key players in the ICU
PTs/PTAs
critical care nurses
respiratory therapists
role of PTs/PTAs in the ICU
provide services that restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities
role of the critical care nurse
provide a high level of skilled nursing for total patient care and often facilitate communication among all the people involved in the care of the patient
role of respiratory therapists in the ICU
work with the critical care team to monitor and promote airway management of the critical care patient. this may include: oxygen therapy, mechanical ventilations management, aerosol medication therapy, cardiorespiratory monitoring, and patient and caregiver education
why do you check in with the ICU nurse before performing treatment?
saves you time
gives you up-to-the-minute status report
can look in on patient on your way to the nurse
general ICU observation skill
snapshot of the patient as you enter the room
systematic approach of taking inventory of a patient’s room
be prepared and have a plan
what are some cardiac monitoring devices?
digital monitor ECG/EKG holter monitor/telemetry external transcutaneous pacemaker transthoracic pacing left ventricular assistive device (LVAD)
LVAD
left ventricular assistive device
implanted mechanical device that helps maintain pumping ability of the heart
telemetry and monitors
usually for continuous monitoring
can sometimes be placed on standby
can view and print vital signs
blood pressure should be monitored…
before, during, and after activity
don’t take blood pressure in the arm with a
pink band
peripheral IV lines
inserted by nurse
hands, arms, or feet
changed often
may infiltrate (red and puffy)
central IV lines
inserted by physician/surgeon within large vein, usually superior or inferior vena cava neck or chest usually in place for several weeks do not infiltrate multipurpose
can an IV line be central?
yes
can a nurse put a central IV line in?
no; a central IV line is put in place by a physician/surgeon
how often does a central line get changed?
they are used for long-term use
can an IV pole serve as a gait device?
yes
how could you make treatment easier if you would like to work on mobility with a patient connected to an IV line?
ask the nursing staff to see if they can disconnect the IV prior to mobilization; making treatment easier.
central venous line red flag notes
inserted through large vein and advanced to the superior vena cava
delivers meds, fluids, blood and total parenteral nutrition
monitors central venous pressure (CVP) via transducer and monitor
allows venous blood draws
common entry sites: subclavian, internal/external jugular, femoral
complications: pneumothorax, venous air embolism
disconnection danger
CVP line
central venous pressure line
if the CVP line is disconnected for patient mobilization, it will need to be recalibrated by the nurse to monitor the patient accurately
types of central venous lines
peripherally inserted central catheter (PICC) tunneled catheter (hickman) implanted port (port-a-cath)
subclavian central line insertion precautions
may have pain with full shoulder ROM. limit to 90˚ because of long catheter extending into right atrium
jugular central line insertion precautions
may have pain with full cervical ROM limit cervical ROM as much as possible
when there is a PICC line, be sure to NOT ____ __ ____ when applying ____ ____
pull on ends; gait belt
port-a-cath
implanted line with access under the skin
needle inserted through skin and into rubber diaphragm
can stay in place for years
arterial lines (A lines)
catheter inserted into an artery (radial or femoral)
connected to pressure tubing and pressure bag: transducer and monitor
clear line that resembles an IV line but does not deliver fluid
measures arterial blood pressure, used to draw blood gases
provides constant readout of a patient’s blood pressure
provides relatively painless access to obtain blood for lab
bags of fluid are present to flush out the line to prevent clots
peripheral pulse = _____ ____ => approximation of what’s happening at the heart
pulse rate
2 reasons for inserting an A line
- to provide a constant beat to beat measurement of the systolic, diastolic, and mean arterial blood pressures (MAP)
- frequent gathering of arterial blood gas samples
note A line ________ and ________ and monitor them during PT sessions
waveform and readings
transducer
small computer chip
converts E from pressure into digital reading
must be leveled at mid-axillary line, 4 ICS (think heart)
used with all types of central lines
A line yellow flags
- the transducer must be level with the patient’s heart. alert RN/staff any time bed height is to be adjusted. if you move the patient, the transducer must be zeroed by the nurse or the measurement will no longer be accurate
- femoral insertion line may kink or break with hip flexion. sitting at 90˚ is usually prohibited. need order from MD to mobilize patients with femoral artery lines
A line red flags
keep A-line connections secure. if disconnected crimp line/turn stop cock, call for help!
stop flow of blood and call for help
what do you do if you accidentally disconnect an A-line?
stop flow of blood and call for help
PA catheter/ Swan-Ganz
long multi-lumen catheter is inserted through the internal jugular vein or subclavian vein and then threaded into heart chambers
gives entire hemodynamic profile for critically ill pts
balloon at tip inflates only to measure PCWP
infuses med, fluids, blood, and TPN
monitors body temperature
allows for rapid blood draws
Swan-Ganz yellow flags
minimal mobility; check with nurse
avoid excessive movement of the line which could cause it to become dislodged or advanced further into the pulmonary artery
Swan-Ganz red flags
mobility is contraindicated when the balloon is in the wedged position within the pulmonary artery due to risk of tearing the arterial wall
communication and coordination with RN/ICU staff are key
PT must have MD OOB activity order
subclavian insertion, limit shoulder ROM to 90˚ due to long catheter passing through heart
jugular insertion: limit cervical ROM as much as possible
if anything gets disconnected or dislodged, crimp, call, and don’t panic
PiCCO Line
pulse contour cardiac output pulmonary artery catheter newer hemodynamic monitoring system swan-like values can be obtained requires an arterial line and a central line
central line Red Flags
never disconnect –> can cause air embolism
femoral line–hip flexion precaution
subclavian–no shoulder elevation > 90˚
jugular–avoid neck motions
what are some types of cardiac devices?
FIGURE THIS OUT
inta-aortic balloon pump (IABP)
lessens heart work load; improves coronary perfusion
cannot flex hip
cannot raise patient’s head of bed greater than 40˚
temporary pacemaker
box must be securely held during mobility
when pacing wires are pulled, patient is placed on bed rest for 1 hour because patient could have arrhythmia due to heart irritation
sequential compression devices
electronic pump that squeezes air through plastic sleeves secured to the patient’s legs with velcro. the stronger compression occurs at the ankle and less more proximally in order to pump venous blood proximally
helps prevent blood clots
pulse oximeter yellow flags
ideally keep O2 sat > 90% even while pt. is exercising
fingernail polish will prevent accurate reading
hypoxia under diagnosed in pts. with darkly pigmented skin
nasal cannula concentration and delivery rate
20-40% 1-6l/min
simple mask concentration and delivery rate
40-60% 5-10l/m
aerosol mask concentration and delivery rate
28-95% 8-15l/min
partial rebreather concentration and delivery rate
70-90% 4-10l/m
non-rebreather concentration and delivery rate
90-100% 10l/m
which oxygen delivery device is used to deliver the greatest concentration at the fasted rate?
non-rebreather
pt. on 2L O2 and pulse ox is low, what should you do next?
look at patient; recheck reading; look at the oxygen
endotracheal tube (ETT)
inserted through the mouth, down the throat, down through the trachea and into the bronchus
tube is connected to ventilator
tracheal tube
inserted through a surgical opening in the neck and trachea
tube is connected to ventilator
what is the difference between and endotracheal tube and a tracheal tube
endotracheal tube is inserted through the mouth; tracheal tube is inserted directly into the trachea
a patient is on a ventilator, what should you make sure to do before moving the patient?
clear tubing of condensation to prevent pneumonia
naso- or endotracheal tube yellow flags
need to clear tubing of condensation prior to mobilizing the patient to prevent fluid flowing down tube and back into patient’s lungs
limit pulling on the tube, which can elicit cough/gag by keeping tubes supported
ventilator
uses positive pressure to inflate lungs
ETT and ventilator yellow flags
empty water/condensation canisters first
avoid excess head/neck movement
mobility is possible, even while patient is intubated
get RN to assist; check MD activity order
can you get someone on a ventilator out of bed?
yes
incentive spirometry
used to help breathe deeper and prevent pneumonia
over inflate alveoli to prevent pneumonia
“hover” technique
inspiration
deep/ET suction
use of a long, flexible tube through the ETT or trach to suction within the airway
yankauer suction
plastic “straw” connected to wall suction with long tubing. allows for suction or oral cavity. suctions people who are on ventilators
passy-muir vlave (PMV)
used over trach to allow patient to speak
SLP should be consulted to guide use during activity as valve does increase pt’s breathing effort
cuff must be deflated while PMV is in use, and only ST/RT can deflate cuff
chest tube
inserted into pleural space to allow for drainage of blood, pus, air, fluid
promotes lung expansion
drains via suction into pleuro-vac container at foot of bed
MD orders required to use portable suction units for ambulation
chest tube red flags
always keep drainage container below level of chest tube insertion
if pt. is on continuous suction, always check with RN/MD if okay to disconnect suction. only disconnect suction tubing at container, not at wall suction canister
keep pleuro-vac vertical. if drainage container falls over, right it and notify nurse immediately
if chest tube becomes dislodged, quickly cover opening in chest with gloved hand to create seal and notify RN
chest tube yellow flags
be careful where you place gait belt. usually best above chest tube
types of drainage tubes/devices
rectal tube
jackson-pratt
hemovac
autovac
jackson-pratt
tubes attached to small plastic or rubber resevoirs that remove blood and other fluid
drainage tube yellow flags
be sure drain is secure before mobilizing–either well taped or safety pinned to patient’s gown
if you pin to gown, unpin at end of session so if gown is changed later, drain will not be pulled out
gastrostomy tube
large rubber tube placed directly into the stomach
used for long term or permanent feeding of a patient
PEG tube yellow flags
often have abdominal binders to prevent pull on tube
do not lay HOB lower than 30 degrees if feeding is running due to risk of aspiration
be careful with gait belt placement
what kinds of things could you do without lying down?
scooting–>anything seated/standing
tube feeding yellow flags
NG, G&J tubes can sometimes be disconnected
TFs must be stopped prior to therapy (½ hour for adult; 1 hour for peds)
do not lay patient flat for ½-1 hour after TF
can you put the gait belt over a binder over a PEG tube?
yes
colostomy yellow flags
be sure seal is good
be sure bag is not overly full before mobilizing patient as it can leak
keep seal dry
be careful with gait belt placement
foley yellow flags
observe urine–quantity and quality
drain urine from tubing into bag before mobility activities. may need to empty bag
know where bag is at all times during bed mobility,, transfers, and ambulation
keep collection bag below bladder
place tubing over leg when positioning in bed
keep tubing off floor. may clip bag to gown with green clip
watch out for pinching or pulling by side rails
watch gait belt placement with urostomy/colostomy bags
consider patient’s dignity
hemodialysis
replaces the filtration function of the kidneys
circulating the patient’s blood outside the body
average of 3x/wk for 3-4 hours per session
affects energy level, BP
what should you do before mobility with someone who has had an epidural?
test motor control
