Overview of Critical Care Flashcards
Definition of Critical Care
critical care nursing is concerned with human responses to life-threatening problems, such as trauma, major surgery, or complications of illness.
The human response can be a physiological or psychological phenomenon (or both). The focus of the critical care nurse includes both pt’s and family’s responses to illness and involves prevention as well as cure.
History of Critical Care
started in 1950s during polio epidemic (iron lung)
1960s: recovery rooms started for care of pts who had undergone surgery
1970s: critical care nursing became specialty
History of AACN (American Association of Critical Care Nurses)
1969: American Association of Cardiovascular Nurses founded to help educate nurses
1971: name changed to American Association of Critical Care Nurses
1974: first year of NTI (National Teaching Institute & Critical Care Exposition)
1975: AACN Certification Corporation founded. Credentialing arm of AACN founded to maintain professional practice excellence through certification.
1976: CCRN critical care specialty certification launched
Other Units that Critical Care has expanded into:
PACU ED Step-down/Intermediate Care Units Interventional Radiology Cardiac Catheterization Lab
Sentinel Events
any unanticipated event in healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness
Goal of Critical Care Nursing
Base core:
- heart and lungs
- secondary interventions
Need to care:
- pt-centered care
- family-centered care
Needs of the Critically Ill Patient
Recall
Needs: feeling safe, receiving information
Nursing Role: technical competence and interpersonal skills promote sense of trust and security
Communication: verbal/nonverbal, touch, therapeutic listening, intubated (make sure they have ways to communicate with us - pen/paper, whiteboard, etc.
Assessment Challenges in Critical Care
Delirium: usually happens w/in 24-48 hours after being admitted to critical care area (most often d/t sleep deprivation)
Neuromuscular Blockade (paralyzing pts): difficult to get a neuro assessment
Management of Pain and Anxiety: differentiating between these two
- one usually exacerbates the other
- pt may be anxious b/c they are in pain, pain is exacerbated when they are anxious
Communication
Pain and Anxiety in Critical Care
Pain:
- unpleasant sensory and emotional experience associated with actual or potential tissue damage
- it is what the pt says it is
Anxiety:
- prolonged state of apprehension in response to fear
- marked by apprehension, agitation, and automatic arousal
Difficult to differentiate pain and anxiety
Relationship is cyclic; one may exacerbate the other
Predisposing Factors that Influence Pain
expectation
previous pain experiences
emotional state
cognitive status (at time of admission)
Predisposing Factors that Influence Anxiety
inability to communicate noise and sensory overload lack of mobility unfamiliar surrounding sleep deprivation circumstances leading to ICU admission (may see pt in ICU b/c of suicide attempt, when they wake up in ICU and see that they've failed at attempt it can be very anxiety inducing)
Sleep in the ICU
two 60min blocks in 7 days
half of the time only one procedure was done
60min sleep cycle provides Stage I or light sleep
90min sleep cycle is needed for a sleep cycle (to reach REM)
lack of sleep leads to problems (physical and psychological)
- need sleep for growth and maintenance of homeostasis
- REM is most important for mental restoration
Sx of Sleep Deprivation
physical and cognitive dysfunction mood instability fatigue depression anxiety stress irritability physical exhaustion
Nursing Interventions for Sleep Deprivation
Tx PADIS: P-pain A-anxiety D-delirium I-immobility S-sleep
Use anti-anxiety meds not Ativan or Valium as these make delirium worse.
5 min back rub increases sleep by an hour
Sedation Assessment Tools
Sedation meds are given to reduce symptoms; dose is adjusted based on tools or scales:
- Richmond Agitation-Sedation Scale (RASS)
- Ramsey Sedation Scale (Ramsey)
- Sedation-Agitation Scale
Propofol
short acting non-benzodiazepine sedative
in OR: used as induction med before intubating
in CC setting: as continuous infusion to keep pt comfortable in sedation so they can tolerate ET tube and ventilator
- fatty emulsion in a 100cc bottle (lipid base)
- lipid base so check cholesterol level if on for greater than 72 hours continuous
- can cause fatty liver if pt has preexisting liver disease (then use other meds like benzos instead)
- made with eggs and soy
- give slowly d/t hypotension and bradycardia
- discard bottle after 12 hours if it hasn’t already run out
- change tubing every 12 hours b/c there is risk for bacteria growth d/t lipid base
- half-life = 15 mins (can easily turn off and do neuro exam)
Delirium
temporary acute confusion for a medical reason (life-threatening)
characterized by:
- acutely changing or fluctuating mental status
- inattention
- disorganized thinking
- altered LOC
Risk Factors of Delirium
dementia HTN ETOH abuse (especially if in withdrawal state) High severity of illness Coma Benzodiazepine administration
Causes of Delirium
dementia dehydration electrolyte imbalances emotional stress lung, liver, heart, kidney, brain disease infection being in ICU itself Rx drugs injury immobility untreated pain unfamiliar environment metabolic disorders
Delirium Assessment Tools
CAM (Confusion Assessment Methods for ICU):
Intensive Care Delirium Screening Checklist
ABCDEF Bundle for Delirium
Awakening & Breathing Trial: wake pt, turn off/down sedation meds, do breathing trials to see if they are ready to come off vent
Choice of Sedative: want to stay away from benzos, Ativan, and Valium. Haldol and Seroquel (antipsychotic/antidepressant) are good.
Delirium Detection: use CAM or other detection tools
Early Progressive Mobility and Exercise: the quicker we can get them out of bed the better. Pt’s on vents can be ambulated by moving to chair and back to bed. Ambulation lowers risk of delirium
Frequent reorientation by nurse and family: helps decrease risk of falls
Falls: strong correlation between falls and delirium, so early detection and management of delirium is crucial
Seroquel
SE: prolonged QT on EKG. Pt gets daily EKG.
Benefit: pt is awake, but chill
- doesn’t interfere with respiratory system/breathing pattern
- pt is cooperative and ambulatory
Chemical Restraints
antipsychotics
typical: haloperidol (Haldol)
atypical:
- Olanzapine (Zyprexa)
- Risperidone (Risperdal)
- Quetiapine (Seroquel)
- NOT Nefazodone (Serzone)
SE:
- QT prolongation (EKG every morning)
- Torsades de pointes
- EPS
Risk Factors for Accidents and Geriatric Trauma
weakness de-conditioning cognitive impairments gait instability loss of sensory perception (visual/auditory disturbances) delayed reaction times chronic illnesses
*trauma is 4th leading cause of death in this population (usually falls)
Cognitive Functioning in the Older Adult
neuropsychologic assessment:
-deterioration of cognitive functioning is not normal expectation of aging
delirium is a frequent complication of critical illness in elderly population
postoperative cognitive dysfunction
dementias
prone to adverse medication interactions
Hospital-Associated Risk Factors for Older Adults
infection multiple concurrent chronicle illnesses exacerbation of pre-existing illness invasive devices nutritional deficiencies inadequate emptying of urine kidneys inability to excrete and absorb certain chemicals int he body
Palliative and End-of-Life Care
relieve suffering
improve quality of life (QOL)
transition care
team collaboration
Obstetric and Postpartum Population
two populations:
- women w/ pre-existing disease who become pregnant
- women w/ normal pregnancies who become critically ill or injured
Physiologic changes:
- only nervous system does not change
- changes begin during 1st week of pregnancy and continue until 6 weeks after delivery
Hypertensive Disease
systolic BP: 140 or greater
diastolic BP: 90 or greater
Pediatric Patient Categories
infancy = 1-12 months toddlers = 1-3 years preschoolers = 3-5 years school-age children = 6-12 years adolescents = 12-18 years
Bronchiolitis
patho: mucosal edema, inflammation, increased mucus production, sloughing of epithelial cells
clinical assessment: sneezing and rhinorrhea
tx: supportive, O2 therapy
Status Asthmaticus
patho: inflammation
clinical assessment: progressive wheezing, cough, SOB, chest tightness
tx: O2 and meds
Cardiac Complications in Pediatric Population
SVT:
- HR greater than 220bpm
- tx = adenosine and cardioversion
Bradycardia:
- HR less than 60bpm (in children)
- HR less than 100bpm (in infants)
- tx: O2 and ventilation
congenital heart defects: occur during embryologic (ventricular septal defect is most common)
acquired heart defects: occur after birth
Neurologic Complications in Pediatric Population
-skull not yet fused
-brain more homogenous and less compartmentalized
increased cerebral blood flow and O2 consumption
-head trauma
-seizures (partial, generalized, unclassified epileptic)
-status epilepticus
-bacterial meningitis
GI, Nutritional and Fluid Complications in Pediatric Population
-gut immunity is lower -> increased mucosal binding of bacterial toxins
Assessment of Pain in Pediatric Population
Up to age 3: behavior scales/physiologic parameters
Age 3-6: child’s verbal statement/behavior scales
Age 6 and up: child’s verbal statement
Ethical Issues in Critical Care
informed consent and confidentiality
withholding or withdrawal of tx
organ and tissue transplantation
distribution of health care resources
Conflicting Principles
Paternalism: beneficence and autonomy
Medical Futility: ineffective or non-beneficial care
- beneficence, nonmaleficence, and autonomy
- continuing to do tx and it’s not going to improve condition of pt
- huge contributor to burn-out in nurses
Ethical Dilemmas: Warning Signs
emotionally charged significant change in pt's condition confusion about facts hesitancy about what is right deviation from customary practice need for secrecy regarding proposed actions (if family member are trying to keep something secret from pt)
POLST
physician orders for life-sustaining treatment:
- medical orders
- support tx decision making
- maximize resources
- decrease moral distress in nurses
DNR
prevent initiation of life-sustaining measures influenced by: -goals of care -comorbidities -pace of clinical decline -availability of surrogate -providers practice patterns
(not the same as withdrawal of life-sustaining treatment = comfort care)
Compassion Fatigue and Burnout
phenomenon that occurs when caregiver feels overwhelmed by repeated empathetic engagement w/ distress patients/families
burnout can manifest as physical, emotional, or spiritual
Compassion Fatigue vs. Burnout
CF: continue to give fully of themselves but find it difficult to maintain healthy balance of empathy and objectivity (sucked into vortex that pulls you slowly downward, can’t stop downward spiral)
-work harder/continue to give to others until completely tapped out
Burnout: adapt to exhaustion by becoming less empathetic and more withdrawn
Final Stages of Burnout
futility
helplessness
uncontrollability
chronic defeatism
