Week 4 Flashcards
How is ICU ward different than regular?
On ICU, more medically unstable, higher medical needs,
On ICU, higher nurse pt ratio ( usually 1 nurse to 4 or 5 pts, ICU = 1:1 / 1 nurse:2 pts )
Characteristics of ICU beds?
Mattresses designed to ease mobility and decrease pressure injuries
ICU mattresses give less pressure to avoid pressure injuries (skin)
Automatic lateral shifts
Easier transfers in/out of bed
Chair position
ICU Beds recline almost to 90 degrees, Sitting position help with breathing and skin issues, avoids the issue of transferring to chair to sit
Even though specialized equipment on ICU is different, they DO NOT replace positioning schedules
Important considerations for patients in ICU
- Level of consciousness (GCS)
- Imaging, lab results
- Pain level
- Vital signs variability
- Lines- IV lines, catheter, chest tube, ventilator line and machine, feeding tube, oxygen line, holter monitor
- Prescribed levels of activity (activity as tolerated- AAT, bed rest)
- Specific oxygen requirements (e.g. keep at above 90%)
- Decreased cognition and/or delirum
Delirium
Confused thinking and reduced awareness of the environment
40% of delirium cases are PREVENTABLE
start of delirium is rapid (within hours or a few days)
Incidence is higher in intensive care units
Recovery after delirium may take months and symptoms may linger for years after
How long does it take to recover from delirium?
Recovery after delirium may take months and symptoms may linger for years after
The onset of delirium is _______
rapid
(within hours or a few days)
40% of delirium cases are _______
PREVENTABLE
What are some ways to prevent delirium:
1) Early mobility and exercise
2) Proper pain management
3) Management of sedatives: benzodiazepines, narcotics
4) Improving sleep
–> Positions for sleep
–> Mental techniques (meditation)
–> pts in ICU generally get 2-8hrs sleep per day
Confusion Assessment Method (CAM)
Outcome measure for identification of delirium at the bedside (often done by nurses)
If pt is ‘cam positive’ = pt is in delirium, if pt is ‘cam negative’ = pt is not in delirium
What does it mean if a pt is ‘cam positive’ or ‘cam negative’
‘cam positive’ = pt is in delirium
‘cam negative’ = pt is not in delirium
What body systems does immobility affect?
Integumentary
Neuromuscular
Cardiovascular/respiratory
Musculoskeletal
Pressure injuries
Injuries to skin and underlying tissue resulting from prolonged pressure on the skin
Warning signs
- Unusual changes in skin color or texture
- Swelling
- Pus-like draining
- An area of skin that feels cooler or warmer to the touch than other areas
- Tender areas
What are warning signs of pressure injuries?
Warning signs
- Unusual changes in skin color or texture
- Swelling
- Pus-like draining
- An area of skin that feels cooler or warmer to the touch than other areas
- Tender areas
The National Pressure Ulcer Advisory Panel (NPUAP) Stages:
Stage 1 – you press on skin and it stays red there is no white (circulation has decreased)
Stage 2 – outer layer of skin is damaged, but other layers are still intact
Stage 3 – multiple layers are damaged, “getting more into core of apple’
Stage 4 – even more layers damaged than stage 3
Unstageable – tendons, muscles are visible
Deep tissue – purple in color, you don’t know what’s underneath necrosis
What NPAUP stage is “multiple layers are damaged, “getting more into core of apple’”
Stage 3
What NPAUP stage is “outer layer of skin is damaged, but other layers are still intact”
Stage 2
What NPAUP stage is “tendons, muscles are visible”
Unstageable
What NPAUP stage is “you press on skin and it stays red there is no white (circulation has decreased)”
Stage 1
What NPAUP stage is “purple in color, you don’t know what’s underneath necrosis”
Deep tissue
What is the scale that assesses a patient’s risk of developing a pressure injury based on 6 criteria
Lower the score, the more severe of developing a pressure injury
Pressure Injury Risk Assessment – Braden Scale
What does it mean if a patient has a low score on Pressure Injury Risk Assessment – Braden Scale
They’re more at risk for developing a pressure injury
Lower the score, the more severe of developing a pressure injury
How often should a patient be turned/re-positioned in bed
every 2 hours, may be re-positioned more frequently if more severe risk
How often should a patient be repositioned in a wheelchair
Patient should do their exercises in their wheel chair every 15 minutes
Good or bad for pressure injuries: wearing socks in bed
Good: it is recommended for pts to wear socks in bed to protect heels
Good or bad for pressure injuries: a pillow under patients legs to suspend their ankles from the bed?
Good: Using a pillow can help protect against heel pressure sores/irritation
Good or bad for pressure injuries: ankle boot to help protect heel?
Debatable: may be areas of redness that develop elsewhere in boot, does protect heel
Good or bad for pressure injuries: side tilted pillow?
Good: helps pt stay on side, if pressure injury on coccyx or sacrum may use this
Good or bad for pressure injuries: bed have fitted sheets over flat sheets
Bad: Causes less friction having flat not fitted sheets and helps pt move easier
Good or bad for pressure injuries: use a blow up mattress on bed?
Good – can deflate and adjust pressure and use for suspension of certain areas of body
Good or bad for pressure injuries: use an air cushion
Good, better pressure distribution
Good or bad for pressure injuries: use a donut cushion?
Bad: donut cushion, cuts circulation and blood pools in hole of donut
Good or bad for pressure injuries: pt be left in a sling in their wheelchair?
Bad, slings can be left on/under pt but this causes more pressure/damage to skin
What degree should the patient be laying in bed at for optimal distribution of pressure
Head of bed at 30 degrees
What is the purpose of a V.A.C. (Vaccum assisted closure)
VAC removes all air and bacteria from pressure sore
Ceiling lifts
Max 400-60 lbs
2 people needed
Floor lifts
- 400-100 lbs max
- Manual or powered
- 2 people needed
Hoyer lift
500 lbs
Tenor lift
700 lbs
Titan lift
1000 lbs
Sit to stand lift
- Lower body of pt unreliable or inconsistent
- Pt move shorter distance
- Rehab tool to introduce early mobility
Factors depending on what lift you should choose to use:
Activity
Size and weight
Condition
