Intensive care nursing Flashcards
define critical care nursing
field of nursing focusing on care of critically ill patients
what are potential causes of life threatening illness?
surgery
illness
injury
list patients in need of critical CCN
CV unstable respiratory distress neurological disease multiple trauma systemic disease extensive wounds electrolyte imbalances sepsis neonates and adolescents
what is the aim of triage for critical patients?
quickly assess patient to determine order of treatment for patients
describe the steps of triage for critical patients
assess 3 MBS
if fail any of MBS assessments need immediate attention
usually takes place in reception with owner
what are the 3 MBS?
neurological
CV
respiratory
what should you make sure to communicate with owners of critical patients during triage?
introduce self and what you will do
ask patients temperament
if stable keep with owner, if not take for treatment and explain someone will be out soon to explain
what is assessed in the quick assessment of triaging critical patients?
HR pulse quality RR and effort bleeding pain mentation ambulation seizure signs MM CRT
what are considerations when monitoring critical patients?
tailor to individual
monitoring equipment can be unreliable
trends more important than results
when do patients need constant monitoring?
critical patients
patients likely to deteriorate
which patients should be monitored every 15-30 minutes?
GA recovery
starting blood transfusion
which patients should be monitored every 1-2 hours?
hypoglycaemic patients
if monitoring RR
when need medication
which patients are monitored every 4-6 hours?
stable patients but may deteriorate
which pulse points are used most for cats and dogs?
dogs- femoral and dorsal pedal
cats- femoral
how is pulse assessed?
feel rate and quality
listen for deficits as indicate arrhythmia
what is suggested by weak and thready, bounding or snappy pulses?
weak or thready- low systolic BP
bounding- sepsis
snappy- anaemia
what needs considering when assessing patients heart rates?
pain
stress
drugs
state normal heart rate for dogs large and small
60-100bpm- large
100-140bpm- small
state HR when tachycardic in dogs
over 140 bpm
state HR when bradycardic in dogs
less than 60bpm
state normal HR in cats
14-180bpm
state HR when tachycardic in cats
over 180-200bpm
state HR when bradycardic on cats
less than 120bpm
what are normal systolic, diastolic and MAP in dogs?
systolic- 110-160mmHg
diastolic- 55-110mmHg
MAP- 100mmHg
what are normal systolic, diastolic and MAP in cats?
systolic- 120-170mmHg
diastolic- 70-120mmHg
MAP- 130mmHg
what BP are classed as hypotensive?
less than 100mmHg systolic and 60mmHg MAP
what BP are classed as hypertensive?
over 170-200mmHg systolic and 120mmHd MAP
how do you respond to hypotension?
give IVFT bolus and vasopressors to cause vasoconstriction
how do you manage hypertension?
give antihypertensive drugs such as amlodipine
investigate cause
how does doppler measure BP?
sound waves detect arterial blood flow
how does oscillometric BP work?
machine reads BPs
what is the benefit of arterial BP measurement?
continuous monitoring of systolic, diastolic and MAP
what colour are normal MM?
pink
what do red/hyperaemic MM suggest?
sepsis
what colour are MM from CO toxicity?
bright red
what do white MM suggest?
anaemia
shock
what do cyanotic MM suggest?
hypoxia
hypoxaemia
what colour do MM go from paracetamol toxicity?
brown
what causes icteric MM?
liver disease
what causes petechia in MM?
coagulopathy
what do dry MM suggest?
dehydration
what is normal CRT?
1-2 seconds
define CRT
amount of time for colour to return to capillary bed after digital pressure applied
what is shown by CRT?
peripheral perfusion
what causes prolonged CRT?
shock
hypoperfusion
vasoconstriction
what causes rapid CRT?
sepsis
vasodilation
what is the purpose of ECG?
measure electrical activity of the heart
what conditions can make patients prone to cardiac arrhythmias?
GDV
sepsis
what are examples of heart abnormalities from auscultation?
murmurs
gallops
pulse deficits
state normal RR for dogs
18-36brpm
state normal RR for cats
20-30brpm
what is considered bradypnoeic?
less than 15brpm
what is considered tachypnoeic?
over 45-60brpm
what can cause bradypnoea?
drugs
hypocapnia
CNS disease
hypothermia
what can cause tachypnoea?
hypoxia hypercapnia pain hyperthermia pyrexia stress metabolic acidosis
define apnoea
absence of ventilatory effort
what can cause apnoea?
respiratory or cardiac arrest
drug overdose
neurological complications
what is seen for normal respiratory effort?
gentle chest movement
minimal abdominal movement
what signs indicate dyspnoea?
increased chest and abdominal muscle movement
orthopnoea
open mouth breathing
what can cause dyspnoea?
airway obstruction
pleural space disease
pulmonary parenchymal disease
upper airway disease
what are signs of reduced respiratory effort?
reduced chest and abdominal muscle movement
what is the danger of reduced respiratory effort?
high risk of cardiac and pulmonary arrest
what can cause reduced respiratory effort?
head injury
spinal cord injury
tetanus
end stage respiratory failure
define stridor
dry noise on breathing
define stertor
wet noise/snore on breathing
what should you listen for when auscultating lungs?
noise on inspiration noise on expiration stridor stertor decreased lung sounds abnormal lung sounds
how should you auscultate lungs?
symmetrically
divide each lung into dorsal, middle and ventral portions and move cranial to caudal
compare each side
what is suggested by decreased lung sounds?
pneumothorax
pleural effusion
what is the purpose of pulse oximetry?
measures oxygenation of blood
what are advantages and disadvantages of pulse oximetry?
adv- non-invasive, continuous monitoring
disadv- doesn’t measure tissue perfusion or ventilation
where do you place pulse oximetery?
tongue
lip
ear
inguinal fold
state normal ETCO2
35-42mmHg
state hypercapnic ETCO2
over 50mmHg
state hypocapnic ETCO2
less than 30mmHg
what makes ETCO2 an indirect assessment of ventilation?
ETCO2 is roughly 1-4mmHg less than arterial PaCO2
what is the advantage of capnography?
non-invasive
what does capnography measure?
ETCO2
what can affect capnography trace?
system leaks ETT kink sensor obstruction airway obstruction apnoea
what is normal PP oxygen?
80-100mmHg
state mild and severe values for hypoxaemia
mild- 70-80mmHg
severe- less than 60mmHg
what does PP oxygen show?
ability to oxygenate blood
what does PP CO2 show?
ability to ventilate and perform gas exchange in alveoli
state normal PP CO2
35-45mmHg
what is hypocapnia PP CO2?
less than 35mmHg
what is hypercapnia PP CO2?
over 45mmHg
what are considerations when giving oxygen therapy?
minimise stress
minimal restraint
be prepared for decompensation and intubation
what are examples of non-invasive oxygen provision?
flow by
oxygen cage
nasal prongs
what are examples of invasive oxygen provision?
nasal catheters
trans-tracheal
endotracheal
ventilation
state how mentation is classed as
normal obtunded stuporous comatose hyper-excitable
define hyper-excitable
excessive reaction to stimuli
what can cause reduced mentation?
shock
hypoperfusion
hypoxaemia
primary neurological disease
list cranial nerve function assessment
PLR
pupil size and symmetry
oculocephalic reflexes
menace reflex
what should be seen in PLR?
both pupils responding bilaterally, rapidly and consensually
what are examples of abnormal pupil size and symmetry?
anisocoria
miosis
mydriasis
define anisocoria
different sized pupils
define miosis
constricted pupils
define mydriasis
dilated pupils
what is meant by oculocephalic reflex?
tracking response of eyes when head moved side to side
what should be seen in menace reflex?
reflex blinking in response to rapid approach to an object
what is nystagmus?
eyes make repetitive, uncontrolled movements
can be horizontal, vertical or rotational
define strabismus
one or both eyes deviated from normal position
what are signs of increased ICP?
absent PLR
pupil changes
describe the modified GCS
3 sections scored out of 6 then totalled
lower the score the worse prognosis
what are the 3 sections in modified GCS?
motor activity- gait, ambulation
brainstem reflexes- PLR, oculocephalic reflex, pupil size
level of consciousness- response to stimuli
when should you alert clinician regarding modified GCS?
if deteriorate 2 or more since last check
what is meant by the cushings reflex?
hypertension and bradycardia as a result of increased ICP
what patients are at risk of ICP?
head trauma
seizures
meningoencephalitis
how should you manage patients with high ICP?
raise head and thorax 15-30 degrees
sternal recumbency to aid ventilation
oxygen
avoid increasing ICP
how can you avoid increasing ICP?
no jugular samples
avoid stimulations to sneeze, gag, vomit
what should you do if patient seizes?
note length and type
how should you manage seizure patients?
cool if hyperthermic have seizure plan on door of kennel keep meds accessible keep in padded kennel give oxygen before and after seizure elevate head and thorax when safe
what needs to be closely observed in patients with lesions to cervical region?
respiratory function
how should you manage spinal trauma patients?
transport on spinal board
minimise movement
keep flat
what are nursing considerations for patients with decreased conciousness?
monitor gag reflex, regurgitation
may need to intubate
physiotherapy
hygiene
list features of critical care wards triage station
ECG portable monitoring equipment exam table BP machine oxygen portable ultrasound consumables
list features of high dependency area
oxygen monitoring equipment observation charts heat sources pumps for meds moveable trolley for access to patient ventilator anaesthetic machine patient easily accessible
what are features of emergency crash station?
easily accessible wheels to allow moving crash table always clear stocked and checked regularly and after use clearly labelled draws of contents
list some equipment found on crash trolleys
ETT and equipment for intubation suction IV consumables pre-drawn saline for flush chest drain equipment IO equipment ECG ambu bag defibrillator essential drugs capnography
what are some essential drugs used in crashes?
adrenaline
atropine
reversal agents
dosage charts
what are some features to make feline friendly areas?
glass doors to see through but reduce noise
windows blocked at bottom to prevent seeing dogs
away from dogs
in quiet area
separate oxygen cages
what are features of nursing station in critical care ward?
able to see whole room
patient records easily accessible
easy computer access
list of important contact numbers
what is the reason for having a lab in critical care ward?
quick diagnosis
use out of hours
what tends to be found in labs in critical care wards?
blood gas/electrolyte machine centrifuge haematology biochemistry coagulation times microscope SNAP tests
what is measured in minimum database?
PCV
TS
blood gas analysis- ventilation, acid base, electrolytes, lactate, oxygenation
blood glucose
what tests are in extended database?
biochemistry haematology urinalysis coagulation profile blood typing and cross matching SNAP tests
what needs to be considered when choosing kennel for patient?
size
walk in
top or bottom
oxygen kennel
when are patients placed in incubators?
neonates
if cant maintain temperature
where do critical patients tend to be kept in the ward?
in cot or trolley
what are some considerations of patient accommodation in critical care ward?
access to nursing and observation access to oxygen temperament visibility barrier nursing recumbency places to hide for cats
list considerations for patient environment in critical care wards
calm and quiet dim light reduced traffic for infection and noise control signs on doors cats separate clean and tidy easy access to consumables access to monitoring equipment
what tends to be found on hospital sheets?
patient and owner details date problem list notify if list tubes, drains, IV lines IVFT and meds information clinical notes weight- admit and daily food intake clinician notes temperament resus status
what measures are in place for infection control?
hand hygiene wiping equipment before and after use gloves prevent HAI barrier nursing
what patients should be barrier nursed?
wounds
potential infectious disease
compromised immune system
what measures are in place to maintain patient hygiene in hospital?
eye lube oral hygiene monitor excretions prevent and treat urine scalding monitor bladder for expression and catheterisation keep on vet bed clean and dry patient if soiled tail bandages
how do you manage hypothermia?
incubator bubble wrap heat mats blankets vet bed warm IVFT
when do and dont you actively cool hyperthermic patients?
if over 40 degrees unless pyrexic as helps fight infection
when do you stop actively cooling hyperthermic patients?
at 39.6 degrees as continue to cool and risk hypothermia
how can you cool hyperthermic patients?
air con
ice under bedding
cooling mats
tepid bath
what consideration is needed for hyperthermic patients?
oxygen needed as higher consumption
how are lines, tubes and drains managed?
checked 2x daily remove as soon as no longer needed treat aseptically label and colour code monitor production from drains
what are the aims of physiotherapy?
decrease complications improve circulation allow muscle and tendon relaxation aid pain management reduce inflammation promote recovery
when is physiotherapy indicated?
pressure sores muscle contraction pulmonary secretions build up muscular weakness atrophy joint stiffness limb swelling pain boredom
when is physiotherapy contraindicated?
unstable patients unstable fractures spinal injury head trauma blood disorders very stressed very painful
what is the importance of providing nutrition to patients in hospital?
enterocytes in GIT need constant direct supply of nutrients
after 3 days of none cells start to die creating weakness in GIT barrier so increased permeability which can lead to bacteria and endotoxins entering systemic circulation
why is it important to try to get early enteral nutrition in critical patients once stable?
may have been anorexic before hospital
what needs to be considered when introducing food to patients in hospital?
refeeding syndrome
list examples of enteral feeding tubes
NO NG oesophagostomy percutaneous endoscopic gastrotomy jejunostomy
why do PEG tubes need to be left for minimum 10 days after placement?
allow adhesions to form to reduce risk of peritonitis
how are patients fed through J tube?
CRI of jejunal diet only
what is meant by parenteral nutrition?
nutrients given directly into patients blood as CRI avoiding GIT
what is the negatives of parenteral nutrition?
less balanced
more expensiv
when is parenteral nutrition used?
non-functioning GIT
unconscious
severe neuro deficits
how is TPN given?
via central line or peripheral central catheter
what is PPN?
40-70% nutrient given parenterally
what are considerations for parenteral nutrition?
strict aseptic technique as sepsis risk
TPN can cause thromboembolisms
new bag and giving set every 24 hours
how can stress be minimised in hospitalised patients?
TLC bonding sedation to allow rest steady for nervous patients reassurance air diffusers hiding spots
how is hypovolaemia managed?
observe compensation mechanisms
fluid bolus of 5-20ml/kg over 10-20 minutes
reassess after each bolus
how is hydration monitored in hospitalised patients?
assess hydration daily
update fluid plan regularly
plan for ongoing losses and maintenance
what is normal UOP?
1-2ml/kg/hr
how is UOP monitored?
monitor ins and outs assess tissue perfusion closed system IDUC weigh bedding weigh patients for rapid changes
how are IDUC managed?
aseptic handling
clean 2x daily
lower than patient but not on floor
prevent patient interference
how can you provide TLC to hospitalised patients?
bond with patient quiet time grooming affection toys time out of kennel hand feeding owner visits
why are nursing care plans used for critical patients?
standardise care so all needs covered and problems highlighted
what are the stages of nursing care plans?
assessment
planning
implementation
evaluation
