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ICU Nursing Flashcards

1
Q

Which patients require critical care nursing?

A

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

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2
Q

How do we carry out a primary triage?

A

Physical assessment of cardiovascular/respiratory/neurological systems
No longer than 2 mins
If patients fails any of these system assessments, they require immediate intervention

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3
Q

How do we communicate with owners during primary triage?

A

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

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4
Q

How do we communicate with clients post-primary survey?

A

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

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5
Q

What are the general principles for monitoring a critical patient?

A

Tailored monitoring to individual patient
Use of monitoring equipment
Good regular physical assessment and keen eye for observation
Recognising trends - deteriorating/improving? Notify clinician?

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6
Q

How often should we be monitoring patients?

A

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

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7
Q

What should be monitoring in the cardiovascular system?

A 
Pulse rate and quality
Heart rate
Blood pressure
Mucous membranes
Capillary refill time
ECG
Heart auscultation
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8
Q

Where can we check pulses in dogs/cats?

A 
Dogs = femoral / dorsal pedal
Cats = femoral
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9
Q

What might differing pulse qualities tell us?

A 
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
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10
Q

What is normal heart rate in dogs and cats?

A

Large dogs = 60-100bpm
Small dogs = 100-140bpm
Cats = 140-180bpm

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11
Q

What HRs are considered tachycardic or bradycardic in dogs and cats?

A

Tachycardia - dogs > 140bpm, cats > 180-200bpm

Bradycardia - dogs < 60bpm, cats < 120bpm

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12
Q

What are normal blood pressure ranges in dogs and cats?

A

Dogs = 110-160 / 55-110 mmHg
Cats = 120-170 / 70-120 mmHg
Normal MAP - dogs ~100mmGg, cats ~ 135mmHg

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13
Q

Describe hypotension in dogs and cats.

A

< 100mmHg systolic
< 60mmHg MAP
Treatment = fluid boluses, vasopressors (drugs that cause vasoconstriction)

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14
Q

Describe hypertension in dogs and cats.

A

> 170-200mmHg systolic
120mmHg MAP
Treatment = antihypertensive drugs e.g. amlodipine, investigate and treat underlying cause

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15
Q

Describe some abnormal MM appearances.

A

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

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16
Q

What is the cause of prolonged CRT?

A

Shock/hypoperfusion

Prolonged CRT due to vasoconstriction

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17
Q

What is the cause of rapid CRT and red/hyperaemic MMs?

A

Sepsis/SIRS

Rapid CRT due to vasodilation

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18
Q

What is the cause of pale MMs and prolonged CRT?

A

Vasoconstriction (shock/hypoperfusion)

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19
Q

When should we use ECG monitoring?

A

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

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20
Q

What are we checking for with heart auscultation?

A

Abnormalities e.g. murmurs, gallop rhythm

Pulse quality and check for pulse deficits

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21
Q

What is the normal respiratory rate for dogs and cats?

A 
Dogs = 18-36brpm
Cats = 20-30brpm
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22
Q

Describe bradypnoea.

A

< 15brpm

Causes = drugs, hypocapnia, CNS diseased (resp. centre affected), hypothermia

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23
Q

Describe tachypnoea.

A

> 45-50brpm

Causes = hypoxia/hypoxaemia, hypercapnia, pain, hyperthermia, pyrexia, stress, compensation for metabolic acidosis

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24
Q

Describe apnoea.

A

Absence of any ventilatory effort (patient has stopped breathing)
Causes = respiratory/cardiac arrest
Drug overdose
Neurological complications e.g. increased ICP

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25
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
26
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
27
Describe decreased respiratory effort.
Reduced chest and abdominal muscle movement | Causes = head and spinal trauma/injury, tetanus, end-stage respiratory fatigue/failure
28
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
29
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
30
What are normal and abnormal capnograph readings?
Normal ETCO2 = 35-45mmHg > 50mmHg = hypercapnia < 30mmHg = hypocapnia
31
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
32
What are normal and abnormal PaO2 values?
Normal range - 80-100mmHg 70-80mmHg = mildly hypoxaemic, may require supplementation < 60mmHg = severely hypoxaemic, oxygen therapy required
33
What are normal and abnormal PaCO2 values?
Normal range = 35-45mmHg < 35mmHg = hypocapnia, indicative of hyperventilation > 45mmHg = hypercapnia, indicative of hypoventilation
34
How can we non-invasively administer O2?
Flow-by e.g. mask, tubing held near mouth/nose Oxygen cage Nasal prongs
35
How can we invasively administer O2?
Nasal catheters Trans-tracheal Endotracheal (intubation) Ventilation - manual IPPV/mechanical
36
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 ```
37
What are the potential causes of reduced mentation?
Shock/hypoperfusion Hypoxaemia e.g. severe anaemia Primary neurological disease
38
Describe the pupillary light reflex.
Pupil response to light e.g. pen torch | Pupils should respond to light bilaterally, rapidly and consensually
39
Describe pupil size and symmetry.
Should be of equal size and shape Anisocoria = pupils are different sizes Miosis = constricted pupils Mydriasis = dilated pupils
40
What is the oculocephalic reflex?
Tracking response of eyes when head moved from side to side
41
What is the menace reflex?
Reflex blinking that occurs in response to rapid approach of an object e.g. hand
42
What is nystagmus?
Eyes make repetitive, uncontrolled movements | May be horizontal, vertical or rotational
43
What is strabismus?
One or both eyes deviate from normal position
44
What do absent pupillary light reflexes/changes in pupil sizes indicate?
Raised ICP e.g. trauma or intracranial lesions (tumour/inflammation)
45
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
46
What is the Cushing's reflex?
Classic response = marked hypertension and bradycardia | Indicates raised ICP
47
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
48
Which patients are at risk of raised ICP?
Head trauma Seizures e.g. status epilepticus Meningoencephalitis patients
49
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
50
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
51
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
52
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 ```
53
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 ```
54
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? ```
55
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
56
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 ```
57
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 ```
58
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 ```
59
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
60
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 ```
61
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
62
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)
63
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 ```
64
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)
65
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
66
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
67
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)
68
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
69
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
70
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 ```
71
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.
72
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
73
Describe dehydration.
Excessive loss of total body water Estimate degree (%) e.g. skin tent, tacky MMs PCV/TS
74
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
75
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
76
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
77
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 ```
78
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

Veterinary Nursing (65 decks)

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