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ICU Nursing Flashcards

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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
Q

Describe dyspnoea.

A

Difficulty/laboured breathing
Postural changes (orthopnoea) e.g. extension of head and neck, abduction of elbows, nostrils flaring on inspiration
Open-mouth breathing

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26
Q

What are some possible causes of dyspnoea?

A

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

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27
Q

Describe decreased respiratory effort.

A

Reduced chest and abdominal muscle movement

Causes = head and spinal trauma/injury, tetanus, end-stage respiratory fatigue/failure

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28
Q

How do we carry out lung auscultation?

A

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

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29
Q

What common abnormalities can we find on lung auscultation?

A

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

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30
Q

What are normal and abnormal capnograph readings?

A

Normal ETCO2 = 35-45mmHg
> 50mmHg = hypercapnia
< 30mmHg = hypocapnia

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31
Q

What factors can affect a capnograph measurement/trace?

A

System leaks
ET tube kink
Sensor obstruction
Airway obstruction e.g. mucous secretions, regurgitation
Apnoea - aids early detection of cardiac arrest

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32
Q

What are normal and abnormal PaO2 values?

A

Normal range - 80-100mmHg
70-80mmHg = mildly hypoxaemic, may require supplementation
< 60mmHg = severely hypoxaemic, oxygen therapy required

33
Q

What are normal and abnormal PaCO2 values?

A

Normal range = 35-45mmHg
< 35mmHg = hypocapnia, indicative of hyperventilation
> 45mmHg = hypercapnia, indicative of hypoventilation

34
Q

How can we non-invasively administer O2?

A

Flow-by e.g. mask, tubing held near mouth/nose
Oxygen cage
Nasal prongs

35
Q

How can we invasively administer O2?

A

Nasal catheters
Trans-tracheal
Endotracheal (intubation)
Ventilation - manual IPPV/mechanical

36
Q

What are the levels of consciousness?

A 
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
Q

What are the potential causes of reduced mentation?

A

Shock/hypoperfusion
Hypoxaemia e.g. severe anaemia
Primary neurological disease

38
Q

Describe the pupillary light reflex.

A

Pupil response to light e.g. pen torch

Pupils should respond to light bilaterally, rapidly and consensually

39
Q

Describe pupil size and symmetry.

A

Should be of equal size and shape
Anisocoria = pupils are different sizes
Miosis = constricted pupils
Mydriasis = dilated pupils

40
Q

What is the oculocephalic reflex?

A

Tracking response of eyes when head moved from side to side

41
Q

What is the menace reflex?

A

Reflex blinking that occurs in response to rapid approach of an object e.g. hand

42
Q

What is nystagmus?

A

Eyes make repetitive, uncontrolled movements

May be horizontal, vertical or rotational

43
Q

What is strabismus?

A

One or both eyes deviate from normal position

44
Q

What do absent pupillary light reflexes/changes in pupil sizes indicate?

A

Raised ICP e.g. trauma or intracranial lesions (tumour/inflammation)

45
Q

Describe the Modified Glasgow Coma Score (MGCS).

A

Three sections, scored out of six - motor activity, brain stem reflexes, level of consciousness
Total score out of 18 - lower score = worse prognosis

46
Q

What is the Cushing’s reflex?

A

Classic response = marked hypertension and bradycardia

Indicates raised ICP

47
Q

How can we treat raised ICP?

A

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
Q

Which patients are at risk of raised ICP?

A

Head trauma
Seizures e.g. status epilepticus
Meningoencephalitis patients

49
Q

How can we manage raised ICP patients?

A

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
Q

What notes should we make if a patient is seizuring?

A

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
Q

What other considerations should we have for neurological patients?

A

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
Q

What are some areas we might see within a critical care ward?

A 
Triage station
High dependency (critical) patient area
Emergency crash station
Feline friendly area
Nursing station
Laboratory area
53
Q

What kind of lab work might we need to carry out on critical patients?

A 
Minimum database (PCV, TS, blood gas analysis)
Biochemistry, haematology
Urinalysis
Coagulation profile
Blood typing/cross matching
SNAP tests
54
Q

What considerations should we have for patient accomodation?

A 
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
Q

How can we provide an optimal environment for patients within the ward?

A

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
Q

What should be noted on a hospital sheet?

A 
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
Q

What nursing considerations should we have in a critical care ward?

A 
Infection control
Hygiene
Body temperature
Lines, tubes and drains
Physiotherapy
Nutrition
Pain and stress
Fluid balance
TLC
58
Q

How can we ensure infection control?

A 
Hand hygiene - before and after each patient
Wiping equipment after each use
Appropriate use of gloves
Prevent HAIs
Barrier nursing - PPE
59
Q

What essential hygiene can we provide for critical patients?

A

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
Q

How can we manage hypothermic patients?

A 
Incubator
Bubble wrap
Heats mats (NOT directly under patient)
Hot hands
Bair hugger
Fleece blanket/vet beds
Warmed IV fluids
61
Q

How can we manage hyperthermic patients?

A

> 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
Q

How do we manage lines, tubes and drains in these patients?

A

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
Q

What are the indications for physiotherapy?

A 
Pressure sores/decubitus ulcers
Muscle contraction/spasm
Build-up of pulmonary secretions
Muscular weakness/atrophy
Joint stiffness
Limb swelling
Pain
Depression/boredom/stress
64
Q

For which patients is physiotherapy contraindicated?

A

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
Q

What are the possible enteral feeding tubes?

A

Nasogastric (NG) or naso-oesophageal (NO) tube
Oesophagostomy (O) tube
Percutaneous endoscopic gastrostomy tube (PEG) tube
Jejunostomy (J) tube

66
Q

What considerations should we have for enteral feeding?

A

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
Q

What is parenteral nutrition?

A

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
Q

What are the two types of parenteral nutrition?

A

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
Q

What considerations should we have when administering parenteral nutrition?

A

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
Q

How can we monitor pain in patients?

A 
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
Q

How can we minimise stress for these patients?

A

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
Q

Describe hypovolaemia.

A

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
Q

Describe dehydration.

A

Excessive loss of total body water
Estimate degree (%) e.g. skin tent, tacky MMs
PCV/TS

74
Q

How can we provide fluid therapy to critical patients?

A

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
Q

How can we monitor urine output?

A

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
Q

How do we care for an indwelling urinary catheter?

A

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
Q

How can we provide patients with TLC?

A 
Lights out / quiet time
Grooming/bathing/affection
Toys (if appropriate)
Time outside of kennel
Hand feeding
Nursing care plans
Owner visits
78
Q

What is included in a nursing care plan and why?

A

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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