ICU Nursing Flashcards
which patients require critical care nursing?
CVS instability
respiratory/neurological distress
multiple trauma (RTA)
systemic disease
extensive wounds/burns
electrolyte imbalances
sepsis/systemic inflammatory response syndrome
what is the aim of triage?
quickly assess each patient to establish whether stable or unstable and decide order of treatment
how do we triage?
quick physical assessment of the 3 major body systems - cardiovascular, respiratory and neurological
how do patients fail a triage?
failing any of the 3 MBS assessments mean they have failed the triage and require immediate intervention
what is involved in the quick initial triage assessment?
check whether tachy/bradycardic, pulse quality
any tachypnoea/dyspnoea, increased respiratory effort
excessive bleeding
severely painful
mentation
ambulatory or not
any seizure activity
mm colour and CRT
which patients require constant monitoring?
critical patients and those likely to deteriorate
which patients require monitoring every 15-30 mins?
GA recovery, those starting a blood transfusion
which patients require monitoring every 1-2 hours?
hypoglycaemic patients
monitoring RR
those needing medication
which patients require monitoring every 4-6 hours?
stable patients but clinical status may deteriorate e.g. coagulopathies, cardiac disease
how can we measure the cardiovascular system function?
pulse rate, heart rate and quality blood pressure mm colour and CRT time ECG heart auscultation
what does it indicate if there are pulse deficits?
indicative of arrhythmias - confirm with ECG
what do weak/thready pulses indicate?
decreased systolic BP e.g. hypovolaemia/hypoperfusion
what do bounding pulses indicate?
sepsis
what do snappy pulses indicate?
indicative of anaemia
what is the normal heart rate for large breed dogs?
60-100 bpm
what is the normal heart rate for small breed dogs?
100-140 bpm
what is the normal heart rate for cats?
140-180bpm
what heart rate is considered tachycardic?
> 140bpm dogs
>180-200bpm cats
what heart rate is considered bradycardic?
<60bpm dogs
<120bpm cats
what is normal MAP?
dogs 100mmHg
cats 135 mmHg
what is normal systolic bp?
dogs 110-160mmHg
cats 120-170mmHg
what blood pressure values are considered hypotensive?
<100mmHg systolic
<60mmHg MAP
what blood pressure values are considered hypertensive?
> 170-200mmHg systolic
>120mmHg MAP
what are the 3 methods of measuring blood pressure?
doppler
oscillometric
invasive BP
how should we take BP readings?
calm quiet environment, allow patient to adjust
lateral recumbency
3-5 readings and average
how large should a BP cuff be?
40% circumference of the leg
what do red/hyperaemic mms indicate?
sepis
what do bright red/cherry red mms indicate?
carbon monoxide toxicity
what do very pale/white mms indicate?
anaemia or shock
what do brown mms indicate?
paracetamol toxicity
what does petechiation on mms indicate?
coagulopathy
what does crt indicate?
peripheral perfusion
what is normal CRT?
1-2 secs
what does prolonged CRT indicate?
> 2.5-3 secs
indicates shock/hypoperfusion
what does rapid CRT plus red/hyperaemic mms indicate?
<1 sec
sepsis/SIRS
rapid CRT due to vasodilation
what does pale mms and prolonged CRT indicate?
vasoconstriction (shock/hypoperfusion)
what does pale mms and normal CRT indicate?
anaemia
which conditions are likely to result in arrhythmias?
GDV and sepsis
how do we assess function of the respiratory system?
RR and effort lung auscultation pulse oximetry capnography arterial blood gases oxygen therapy and considerations
what is the normal RR range in dogs and cats?
dogs 18-36 brpm (breed size dependent)
20-30 brpm
what is considered bardypnoea?
<15 brpm
what are some possible causes of bradypnoea?
drugs
hypocapnia
CNS disease (respiratory centre affected)
hypothermia
what is considered tachypnoea?
> 45-50 brpm
what are some of the causes of tachypnoea?
hypoxia/hypoxaemia hypercapnia pain hyperthermia pyrexia stress compensation for metabolic acidosis
what are some possible causes of apnoea?
respiratory or cardiac arrest
drug overdose
neurological complications
what are some of the causes of dyspnoea?
upper airway obstruction, flail chest
pleural space disease
pulmonary parenchymal disease
upper airway disease (BOAS, laryngeal paralysis)
what are the indications a patient is dyspnoeic?
increased chest and abdominal muscle movement postural changes (orthopnoea) open-mouth breathing
why might a patient display reduced respiratory effort?
head and spinal trauma/ijury
tetanus
end stage respiratory failure/fatigue
what does decreased dorsal lung sounds indicate?
pneumothorax (air in pleural space)
what does decreased ventral lung sounds indicate?
pleural effusion (fluid in pleural space)
what does borborygmi sounds in the lung field indicate?
diaphragmatic rupture
what do crackles/wheezes on lung auscultation indicate?
bronchopulmonary disease e.g. pulmonary oedema, pulmonary contusions, damage/disease of lung parenchyma
where can you place a pulse oximeter?
tongue lip ear inguinal fold prepuce vulva
what is a normal ETCO2 value?
35-45 mmHg
which factors can affect the capnography measurement/trace?
system leaks ET tube kink sensor obstruction airway obstructions apnoea (aids early detection of cardiac arrest)
what is PaO2?
amount of O2 dissolved in arterial blood
what is PaCO2?
amount of CO2 dissolved in arterial blood
what is normal PaO2 range?
80-100 mmHg
what is normal PaCO2 range?
35-45 mmHg
where do we obtain an arterial blood sample from?
dorsal pedal artery
what non-invasive methods of oxygen provision are available?
flow-by oxygen e.g. mask, tubing held near patients mouth/nose
oxygen cage
nasal prongs
what invasive methods of oxygen delivery are available?
nasal catheters
trans-tracheal
endotracheal (intubation)
(IPPV or mechanical)
how do we assess neurological system function?
mentation
cranial nerve function
modified glasgow coma score (MGCS)
increased intracranial pressure
seizures
what does obtunded mean?
reduced alertness/consciousness, easily roused with non-noxious stimuli
what does stuporous mean?
unconscious, only rousable with noxious stimuli
what does comatose mean?
unconscious, no response to any stimuli, including noxious stimuli
what are some potential causes of reduced mentation?
shock/hypoperfusion
hypoxaemia e.g. severe anaemia
primary neurological disease
how can we assess cranial nerve function?
pupillary light reflex pupil size and symmetry oculocephalic reflexes menace relfex nystagmus strabismus
what is miosis?
constricted pupils
what is mydriasis?
dilated pupils
what is nystagmus?
eyes making repetitive, uncontrolled movements - may be horizontal/vertical/rotational
what is strabismus?
one or both eyes deviated from normal position
what can absent PLRs or changes in pupil size indicate?
raised ICP - trauma or intra-cranial lesions (tumour, inflammation)
what are the 3 sections of the modified glasgow coma score?
motor activity
brainstem reflexes
level of consciousness
what is cushing’s reflex?
marked hypertension and bradycardia
what does cushings reflex indicate?
raised ICP - emergency
what can be given to try and lower ICP?
mannitol
hypertonic saline
which patients are most at risk of raised ICP?
head trauma
seizures
meningoencephalitis patients
how can we help manage raised ICP?
elevate head and thorax up by 15-30°
sternal recumbency to aid respiratory ventilation, provide O2
no jugular sample
avoid stimulation to sneeze/gag/vomit
how can we manage seizure patients?
may require active cooling
provide flow-by oxygen during/after seizures
elevate head and thorax once safe to do so
make sure in padded kennel with seizure medications readily available
what other considerations are there for patients with lesions of cervical region?
closely monitor respiratory function
what other considerations are there for spinal trauma patients?
spinal board for transport and movement for potentially unstable spines
keep flat, minimise movement
what other considerations are there for patients with decreased consciousness?
monitor gag reflex, regurgitation
may require airway protection
physiotherapy
hygiene e.g. eye and oral care
what are the areas of a critical care ward?
triage station high dependency (critical) patient area emergency crash station feline-friendly area nursing station laboratory area
what should there be in the triage area?
oxygen supply
portable ultrasound machine (free fluid checks)
consumables
examination table
portable monitoring equipment
telemetry for ECG
blood pressure machine
good space to move
what equipment should there be in the high dependency area?
oxygen supply monitoring equipment chart for observation and recording pumps and syringe drivers heat source for patient moveable trolley ventilator/anaesthetic machine easy access/space for constant patient monitoring
what are the features of a feline friendly ward?
glass doors - easy to see through but provides noise reduction
glass cover - cats cannot see dogs walking past
oxygen and electricity wall access
separate oxygen cages
what are the important features of a critical care nursing station?
list of important contact numbers
computer access for charging/px records/emergency details
able to observe whole room
patient records to hand
which equipment might feature in the laboratory area?
blood gas/electrolyte machine microscope centrifuge diff-quik stain haematology machine biochemistry machine coagulation times SNAP tests
what type of laboratory work might be carried out in critical care?
minimum database (PCV/TS, electrolytes, lactate, oxygenation/ventilation, glucose) biochemistry and haematology urinalysis coagulation profiling blood typing blood cross-matching SNAP tests
what information should be on the hospital sheet?
patient and owner details date problem list tubes/drains/IV lines IVFT and medications due clinical notes admin weight and daily weight record daily record of RER and food intake clinicians notes clinician in charge and contact details patient temperament
what categories of nursing considerations must be attended to in critical care?
infection control hygiene body temperature lines/tubes/drains physio nutrition pain and stress fluid balance TLC
what are the basic principles of infection control?
hand hygiene - wash before and after each patient wipe equipment after use appropriate use of gloves prevent HAIs PPE if barrier nursing
how can we keep the patient warm?
incubator bubble wrap heat mats (not directly under patient!) hot hands bair hugger fleece blankets/vet beds warmed IV fluids
how can we cool a hyperthermic patient?
fan/air conditioning ice under bedding cooling mats cold damp bedding/towels tepid water bath frequently re-check temperature!
how often should we check lines/tubes/drains of critical cate patients?
minimum twice daily
remove as soon as no longer required
what are the general aims of physiotherapy for critical care patients?
decrease chance of complications e.g. recumbent patients
improve circulation
allow muscle/tendon relaxation
aid pain management
reduce inflammation
promote recovery
what are the indications for physiotherapy?
pressure sores/decubitus ulcers muscle contractions/spasm buildup of pulmonary secretions muscular weakness/atrophy joint stiffness limb swelling pain depression/boredom/stress
what are the contraindications for physiotherapy?
unstable critical patients unstable limb/spinal fractures or spinal injuries head trauma blood disorders very stressed/painful patients
what happens if there is no nutrients in the GI tract for >3 days?
cells will start to die - creates weakness in the GI tract barrier
what does weakness of the GI barrier lead to?
increased intestinal permeability - bacteria and endotoxins can cross barrier and enter systemic circulation (translocation)
impaired immune function of GIT
how do you avoid refeeding syndrome in anorexic patients?
1/3 RER on day 1, 2/3 RER on day 2 etc
what are the different types of enteral feeding tube?
NG/NO tube
oesophagostomy tube
percutaneous endoscopic gastrotomy (PEG) tube
jejunostomy tube
what are the considerations for patients with enteral feeding tubes?
check tube in correct location before every feed
check insertion site at least BID, clean site
sit in sternal/elevate thorax to prevent regurgitation and aspiration
J tube must have specific jejunal diet only
how long must PEG/J-tubes be left in? why?
minimum of 10-14 days
allows adhesions to form to reduce risk of peritonitis upon removal
what is parenteral nutrition?
nutrients are provided directly into patients blood stream, avoiding GIT
what is total parenteral nutrition?
all nutrients parenterally
high osmolality
given via central line/peripherally inserted central catheter (PICC line)
what is partial parenteral nutrition?
40-70% of nutrients given parenterally
may be given via central or peripheral route
what are the considerations for parenteral feeding?
strict aseptic technique - can cause sepsis
TPN NOT peripherally - can cause thrombophlebitis
new bag and giving set every 24 hours
what can we use to assess pain in cats?
feline glasgow pain score/colorado cat pain score
what can we use to assess pain in dogs?
canine glasgow composite pain scale
how can we minimise stress in critical care patients?
TLC - strengthen nurse/patient bond
sedative drugs to allow periods of rest
take your time/go slow with nervous patients
reassurance
feliway cat diffuser
hiding areas
how can we monitor urine output?
closed system IDUC
weight incontinence sheets/bedding/litter
weight at least once daily - fluid balance responsible for rapid changes in patients weight
what is a normal UOP?
1-2 ml/kg/hr
how can we provide TLC to critical care patients?
quiet time and lights out time grooming/bathing/affection toys (if appropriate) time outside the kennel hand-feeding
nursing care plans
owner visits
what is the purpose of a nursing care plan?
standardisation of nursing care -
ensures patients needs met and all areas of nursing are covered
highlights any problems/potential complications
