ICU Nursing Flashcards
Which patients require critical care nursing?
Cardiovascularly unstable e.g. hypovolaemic, unstable anaemia
Respiratory distress e.g. pleural effusion
Neurological disease e.g. increased ICP, status epilepticus
Multiple trauma e.g. RTA
Systemic disease e.g. diabetic ketoacidosis, Addisonian crisis
Patients with extensive wounds/burns
Electrolyte imbalances e.g. hypocalcaemia, hyperkalaemia
Sepsis/systemic inflammatory response syndrome (SIRS) e.g. foreign body rupturing GI tract resulting in septic peritonitis
Neonates/adolescents e.g. parvovirus
How do we carry out a primary triage?
Physical assessment of cardiovascular/respiratory/neurological systems
No longer than 2 mins
If patients fails any of these system assessments, they require immediate intervention
How do we communicate with owners during primary triage?
Introduce yourself - name, role, brief summary of what you are intending to do next
Ask client if patient is friendly - safety still paramount
If patient stable, can stay with owner
If patient obviously unstable e.g. not breathing/unresponsive, immediately take from owner for emergency treatment
How do we communicate with clients post-primary survey?
Explain what you have found and why you are concerned
Ask permission to take patient for further assessment and/or treatment
Explain someone will be back shortly to give update and collect full history
Remember - client may be very distressed
What are the general principles for monitoring a critical patient?
Tailored monitoring to individual patient
Use of monitoring equipment
Good regular physical assessment and keen eye for observation
Recognising trends - deteriorating/improving? Notify clinician?
How often should we be monitoring patients?
Constant = critical patients and those likely to deteriorate
Every 15-30mins = e.g. GA recovery, starting blood transfusion
Every 1-2hrs = e.g. hypoglycaemic, monitoring RR, needing medication
Every 4-6hrs = stable patients but clinical status may deteriorate e.g. coagulopathies, cardiac disease
What should be monitoring in the cardiovascular system?
Pulse rate and quality Heart rate Blood pressure Mucous membranes Capillary refill time ECG Heart auscultation
Where can we check pulses in dogs/cats?
Dogs = femoral / dorsal pedal Cats = femoral
What might differing pulse qualities tell us?
Weak/thready pulses - indicative of decreased systolic BP e.g. hypovolaemia/hypoperfusion Bounding pulses (strong and longer duration - indicative of sepsis Snappy pulses (strong and shorter duration) - indicative of anaemia
What is normal heart rate in dogs and cats?
Large dogs = 60-100bpm
Small dogs = 100-140bpm
Cats = 140-180bpm
What HRs are considered tachycardic or bradycardic in dogs and cats?
Tachycardia - dogs > 140bpm, cats > 180-200bpm
Bradycardia - dogs < 60bpm, cats < 120bpm
What are normal blood pressure ranges in dogs and cats?
Dogs = 110-160 / 55-110 mmHg
Cats = 120-170 / 70-120 mmHg
Normal MAP - dogs ~100mmGg, cats ~ 135mmHg
Describe hypotension in dogs and cats.
< 100mmHg systolic
< 60mmHg MAP
Treatment = fluid boluses, vasopressors (drugs that cause vasoconstriction)
Describe hypertension in dogs and cats.
> 170-200mmHg systolic
120mmHg MAP
Treatment = antihypertensive drugs e.g. amlodipine, investigate and treat underlying cause
Describe some abnormal MM appearances.
Red/hyperaemic = sepsis
Bright/cherry red = carbon monoxide toxicity
Very pale/white = anaemia or shock
Cyanotic/blue/grey = hypoxia/hypoxaemia e.g. apnoea
Brown = paracetamol toxicity
Icteric/jaundice/yellow = liver disease or haemolysis
Petechiation = coagulopathy
Tacky/dry = dehydration
What is the cause of prolonged CRT?
Shock/hypoperfusion
Prolonged CRT due to vasoconstriction
What is the cause of rapid CRT and red/hyperaemic MMs?
Sepsis/SIRS
Rapid CRT due to vasodilation
What is the cause of pale MMs and prolonged CRT?
Vasoconstriction (shock/hypoperfusion)
When should we use ECG monitoring?
Important in crash scenario
Some conditions likely to have arrhythmias e.g. GDV and sepsis
Constant for all cardiac patients e.g. ventricular tachycardia, AV blocks
What are we checking for with heart auscultation?
Abnormalities e.g. murmurs, gallop rhythm
Pulse quality and check for pulse deficits
What is the normal respiratory rate for dogs and cats?
Dogs = 18-36brpm Cats = 20-30brpm
Describe bradypnoea.
< 15brpm
Causes = drugs, hypocapnia, CNS diseased (resp. centre affected), hypothermia
Describe tachypnoea.
> 45-50brpm
Causes = hypoxia/hypoxaemia, hypercapnia, pain, hyperthermia, pyrexia, stress, compensation for metabolic acidosis
Describe apnoea.
Absence of any ventilatory effort (patient has stopped breathing)
Causes = respiratory/cardiac arrest
Drug overdose
Neurological complications e.g. increased ICP
Describe dyspnoea.
Difficulty/laboured breathing
Postural changes (orthopnoea) e.g. extension of head and neck, abduction of elbows, nostrils flaring on inspiration
Open-mouth breathing
What are some possible causes of dyspnoea?
Upper airway obstruction / flail chest (can have paradoxical breathing)
Pleural space disease e.g. pleural effusion, pneumothorax, diaphragmatic rupture
Pulmonary parenchymal disease e.g. pulmonary contusions, pulmonary oedema, pneumonia
Upper airway disease e.g. BOAS, laryngeal paralysis
Describe decreased respiratory effort.
Reduced chest and abdominal muscle movement
Causes = head and spinal trauma/injury, tetanus, end-stage respiratory fatigue/failure
How do we carry out lung auscultation?
Listen to breathing from a distance and observe breathing pattern
Noise on inspiration/expiration/both?
Auscultate thorax in systematic manner - divide hemi-thorax (L and R lungs) into dorsal, middle and ventral lung fields, auscultate each lung field cranial to caudal, compare adjacent lung fields and L/R lungs
What common abnormalities can we find on lung auscultation?
Decreased/absent lung sounds - dorsally = pneumothorax, ventrally = pleural effusion
Borborygmi (gut sounds) = diaphragmatic rupture
Crackles/wheezes = bronchopulmonary disease e.g. pulmonary oedema, pulmonary contusions, damage/disease of lung parenchyma e.g. pneumonia
What are normal and abnormal capnograph readings?
Normal ETCO2 = 35-45mmHg
> 50mmHg = hypercapnia
< 30mmHg = hypocapnia
What factors can affect a capnograph measurement/trace?
System leaks
ET tube kink
Sensor obstruction
Airway obstruction e.g. mucous secretions, regurgitation
Apnoea - aids early detection of cardiac arrest
What are normal and abnormal PaO2 values?
Normal range - 80-100mmHg
70-80mmHg = mildly hypoxaemic, may require supplementation
< 60mmHg = severely hypoxaemic, oxygen therapy required
What are normal and abnormal PaCO2 values?
Normal range = 35-45mmHg
< 35mmHg = hypocapnia, indicative of hyperventilation
> 45mmHg = hypercapnia, indicative of hypoventilation
How can we non-invasively administer O2?
Flow-by e.g. mask, tubing held near mouth/nose
Oxygen cage
Nasal prongs
How can we invasively administer O2?
Nasal catheters
Trans-tracheal
Endotracheal (intubation)
Ventilation - manual IPPV/mechanical
What are the levels of consciousness?
Normal = alert, responds appropriately to stimuli Obtunded = reduced alertness/consciousness, easily roused with non-noxious stimuli Stuporous = unconscious, only rousable with noxious stimuli Comatose = unconscious, no response to any stimuli Hyper-excitability = excessive reaction to stimuli
What are the potential causes of reduced mentation?
Shock/hypoperfusion
Hypoxaemia e.g. severe anaemia
Primary neurological disease
Describe the pupillary light reflex.
Pupil response to light e.g. pen torch
Pupils should respond to light bilaterally, rapidly and consensually
Describe pupil size and symmetry.
Should be of equal size and shape
Anisocoria = pupils are different sizes
Miosis = constricted pupils
Mydriasis = dilated pupils
What is the oculocephalic reflex?
Tracking response of eyes when head moved from side to side
What is the menace reflex?
Reflex blinking that occurs in response to rapid approach of an object e.g. hand
What is nystagmus?
Eyes make repetitive, uncontrolled movements
May be horizontal, vertical or rotational
What is strabismus?
One or both eyes deviate from normal position
What do absent pupillary light reflexes/changes in pupil sizes indicate?
Raised ICP e.g. trauma or intracranial lesions (tumour/inflammation)
Describe the Modified Glasgow Coma Score (MGCS).
Three sections, scored out of six - motor activity, brain stem reflexes, level of consciousness
Total score out of 18 - lower score = worse prognosis
What is the Cushing’s reflex?
Classic response = marked hypertension and bradycardia
Indicates raised ICP
How can we treat raised ICP?
Emergency - osmotic diuretics to reduce brain swelling/oedema, e.g. mannitol/hypertonic saline
Monitor closely - MGCS, HR, BP, RR q1-6hrs depending on stability
Which patients are at risk of raised ICP?
Head trauma
Seizures e.g. status epilepticus
Meningoencephalitis patients
How can we manage raised ICP patients?
If possible, elevate head and thorax upwards by 15-30 degrees
Sternal recumbency, provide O2
Avoid inadvertently raising ICP - no jugular samples, avoid stimulation to sneeze e.g. intranasal catheters or nasal prongs, avoid stimulation to gag e.g. intubating a light patient, morphine
What notes should we make if a patient is seizuring?
Length of seizure (e.g. drug intervention after seizure is > 2 mins long)
Partial e.g. facial twitching, jaw chomping, fly catching etc. OR full e.g. tonic-clonic seizure
What other considerations should we have for neurological patients?
Lesions of cervical region - closely monitor resp. function
Spinal trauma patients - spinal board for transport, keep flat, minimise movement
Patients with decreased consciousness - monitor gag reflex, regurgitation, may require airway protection e.g. intubation, physiotherapy and hygiene e.g. eye and oral care
What are some areas we might see within a critical care ward?
Triage station High dependency (critical) patient area Emergency crash station Feline friendly area Nursing station Laboratory area
What kind of lab work might we need to carry out on critical patients?
Minimum database (PCV, TS, blood gas analysis) Biochemistry, haematology Urinalysis Coagulation profile Blood typing/cross matching SNAP tests
What considerations should we have for patient accomodation?
Kennel size Walk-in/top/bottom kennel Oxygen kennel Incubator Cot/trolley for critical patients Access for nursing care and observation Proximity to O2 and electricity Breed/temperament Barrier nursing? Recumbent?
How can we provide an optimal environment for patients within the ward?
Calm, quiet +/- dim lighting
Reduce people traffic - infection/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
What should be noted on a hospital sheet?
Patient/owner details Date Problem list and 'notify if' list Tubes, drains and IV lines IVFT and meds due Clinical notes Admit weight + daily record of weight Daily record of RER Record of food intake Clinician in charge, contact details and notes Patient temperament
What nursing considerations should we have in a critical care ward?
Infection control Hygiene Body temperature Lines, tubes and drains Physiotherapy Nutrition Pain and stress Fluid balance TLC
How can we ensure infection control?
Hand hygiene - before and after each patient Wiping equipment after each use Appropriate use of gloves Prevent HAIs Barrier nursing - PPE
What essential hygiene can we provide for critical patients?
Eye lubrication as required
Oral hygiene
Monitor urine/faecal incontinence, prevent and treat urine/faecal scalding
Bladder expression / catheterisation
Vet beds to wick urine away from patient
If soiled - clean with animal friendly shampoo, dry after washing to prevent hypothermia
Tail bandages
How can we manage hypothermic patients?
Incubator Bubble wrap Heats mats (NOT directly under patient) Hot hands Bair hugger Fleece blanket/vet beds Warmed IV fluids
How can we manage hyperthermic patients?
> 40 degrees C actively cool (unless pyrexic)
Fan/air conditioning
Ice under bedding
Cooling mats
Cold damp bedding/towels (NOT placed over top of patient)
Tepid water bath
Frequently recheck temp. q1min - stop active cooling at ~39.6 degrees C
Oxygen flow-by
+/- sedation
How do we manage lines, tubes and drains in these patients?
Check minimum of twice daily
Standard operating protocol (SOP) - all staff manage the same
Remove as soon as no longer required
Treat aseptically i.e. handwashing, gloves
Label/colour code all lines (fluid lines, feeding tubes, chest drains, IV and arterial catheters)
Monitor and record fluid production/type from drains etc. (calculate ml/kg/hr for fluid production)
What are the indications for physiotherapy?
Pressure sores/decubitus ulcers Muscle contraction/spasm Build-up of pulmonary secretions Muscular weakness/atrophy Joint stiffness Limb swelling Pain Depression/boredom/stress
For which patients is physiotherapy contraindicated?
Unstable critical patients
Unstable limb/spinal fractures of spinal injuries
Head trauma
Blood disorders e.g. thrombocytopenia
Very stressed/painful patients (must be appropriately analgesed before attempting physio)
What are the possible enteral feeding tubes?
Nasogastric (NG) or naso-oesophageal (NO) tube
Oesophagostomy (O) tube
Percutaneous endoscopic gastrostomy tube (PEG) tube
Jejunostomy (J) tube
What considerations should we have for enteral feeding?
Check tube in correct location before every feed (always use sterile water first)
Check insertion site at least BID, clean site (e.g. dilute povidone iodine) - observe for redness, swelling or discharge
Sit in sternal/elevate thorax to prevent regurgitation and aspiration
PEG/J tube must be left in situ for a minimum of 10-14 days after placement (allows adhesions to form to reduce risk of peritonitis upon removal)
J-tube = CRI of specific jejunal diet only
What is parenteral nutrition?
Nutrients provided directly into patient’s bloodstream, avoiding GI tract
Delivered as a CRI
Less balanced nutrition than enteral feeding
Much more expensive for client
Only considered when enteral feeding is not an option (e.g. non-functioning GI tract, severe neurological deficits, unconscious patients)
What are the two types of parenteral nutrition?
Total parenteral nutrition = all nutrients parenterally, high osmolality so give via central line/peripherally inserted central catheter (PICC line)
Partial parenteral nutrition = 40-70% nutrients given parenterally, may be given via central or peripheral route
What considerations should we have when administering parenteral nutrition?
Strict aseptic technique - can cause sepsis as breeding ground for bacteria
Total not given peripherally - can cause thrombophlebitis
New bag and giving set every 24hrs
How can we monitor pain in patients?
Feline Glasgow Pain Score/Colorado Cat Pain Score Canine Glasgow Composite Pain Scale Reassess patients at repeated intervals Review analgesia plan frequently Do not confuse pain and stress
How can we minimise stress for these patients?
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 e.g. boxes/blankets over kennel door etc.
Describe hypovolaemia.
Decreased intravascular blood volume
Emergency situation, compensation e.g. tachycardia and peripheral vasoconstriction
Fluid boluses 5-20ml/kg over 10-20mins
Reassess after each fluid bolus
Describe dehydration.
Excessive loss of total body water
Estimate degree (%) e.g. skin tent, tacky MMs
PCV/TS
How can we provide fluid therapy to critical patients?
Assess hydration status daily, fluid therapy plan updated regularly according to clinical status
Plan should account for ongoing losses (e.g. V+/D+) and drains (e.g. abdominal/thoracic)
Maintenance rate = 2ml/kg/hr
Type of fluid therapy decided based on patient’s clinical condition
Whole blood or packed RBCs - given if excessive blood loss during surgery/trauma/severe anaemia etc
How can we monitor urine output?
Closed system i.e. indwelling urinary catheter
Weigh incontinence sheets, bedding and litter
Weigh patient at least once daily - fluid balance responsible for rapid changes in weight
Normal UOP = 1-2ml/kg/hr
How do we care for an indwelling urinary catheter?
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
How can we provide patients with TLC?
Lights out / quiet time Grooming/bathing/affection Toys (if appropriate) Time outside of kennel Hand feeding Nursing care plans Owner visits
What is included in a nursing care plan and why?
Assessment, planning, implementation and evaluation
Standardisation of nursing care - ensures patient’s needs met and all areas of nursing covered, highlights any problems/potential complications
