Wk 1 Flashcards
History of crit care
Understanding pathophysiology 1&2 WW
Advances following polio epidemic in Copenhagen 1952 - mortality associated with resp 87% to 26%, negative pressure ventilation (iron lung), Bjorn Ibsen introduced positive pressure ventilation
Critically ill patients were grouped together
Critical care functions
Require support for:- Haemodynamic instability Airway or resp compromise Acute renal failure Lethal cardiac arrhythmia Multiple organ system failure
May also be admitted for intensive invasive monitoring such as crucial hours after major surgery or deemed too unstable to transfer to less intensively monitored unit
Specialist area: ICU
Patients requiring or likely to require advanced respiratory support
Multiple life threatening problems
Multiple organ dysfunction
Requiring support of 2 or more organs
Invasive monitoring and cardio-active drugs
Haemofiltration
Specialised area: high dependency care
Level of care intermediate between that on general ward and intensive care
Monitors and supports patients with or likely to develop, acute single organ failure
Patients that:
Require <40% oxygen
Unstable resp condition likely to deteriorate
Non-invasive CPAP/BI-PAP
Tracheostomy that requires frequent suctioning
Unstable cardiovascular function
Inotropic support
Epidural analgesia
Impaired renal function/fluid imbalance
Step down patients
Specialised area: emergency department
Patients are triaged and categorised on arrival
Specialised areas designed to care for the critically ill patients RESUS
Very much like a HDU
Ready for standby alerts
Not all patients are urgent
ED: Australian Triage System
Structure by which all incoming emergency patients are prioritised
Purpose is to ensure that the level of emergency care provided is commensurate with clinical criteria
The urgency determined according to patients condition on arrival
Specialised area: coronary care unit
Patients with reversible cardiac conditions
Frequently post MI
At high risk of deterioration
Extensive and invasive monitoring used to detect changes in condition
Capable of administering thrombolysis
Work with Cath Labs
Specialised area: theatre department
Operations and invasive procedures
Have both “list” and “emergency” theatres
Patients may be seriously ill prior to surgery
May suffer sever homeostatic imbalance due to surgery and or drugs
Intensive Haemodynamic monitoring to detect changes
Critical care classification
Level 0: patients whose needs can be met through normal ward care in an acute hospital
Level 1: patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from crit care team
Level 2: patients require more detailed obs or intervention including support for a single failing organ system or post-op care and those ‘stepping down’ from higher levels of care
Level 3: patients require advanced resp support alone or basic resp support together with support of at least 2 organ systems. This level includes all complex patients requiring support for multi-organ failure.
Contemporary approach to critical care
Flexible use of beds and reduction of the boundaries between ITU/HDU/Ward beds
Flexible and skilled nursing staff with crit care skills
New strategies: MET, EWS and Audits
Outreach supports
Management of critically ill
Nurses are first point of contact
Knowledge and understanding underpins decision making process
As a nurse you must be responsible for identifying appropriate time to summon help
Management of patients requires excellent assessment skills and teamwork
MDT involvement
Patients go on to be managed by specialists
RRCD
Recognising and responding to deteriorating patient
Things that can go wrong with care of the acutely unwell
Development of acute illness Lack of recognition Inadequate monitoring and interpretation Physiological deterioration Organ failure Multi-organ failure Cardio-respiratory arrest
Define critical care
Branch of medicine and nursing concerned with the provision of organ or life support
Patients require intensive monitoring
Patients are at high risk of actual or potential life threatening health problems
Specialised nursing care of critically ill patients who have manifest or potential disturbances in vital organ function. Assist, support and restore patient to health or ease patients pain and prepare for dignified death.
The at risk patients
Emergency admissions Trauma Exacerbation of pre-existing diseases Sever acute illness Failure to progress after Tx Shocked patients Recovering from anaesthesia Re-bleeding after surgery Massive blood transfusion
What is assessment?
Gather info relevant to dealing with actual problem or potential problems
Identify causative factors and abnormalities
Various types of assessment for at risk patients
Visual assessment
Verbal assessment
Vital signs
Risk assessment: scoring tools
EWS
Early intervention is key
Monitoring physiological parameters key to detecting critical illness
Track and trigger system
Airway management
Problems: CNS depression, blood, trauma, foreign body, bronchospasm, inflammation
Look: colour, swelling, secretions, obstructions
Listen: speaking, gurgling, strider, snoring
Feel: airflow from mouth and nostrils
Management: ensure its patent and maintained Simple airway manoeuvres Position Suction Adjuncts
Breathing management
Problems: resp disease, infection, pain, muscle weakness, CNS depression
Look: resp rate, pattern, depth, O2 sats, symmetry if chest, accessory muscles
Listen: oriented, wheeze, crackles, full sentences
Feel: chest expansion, tracheal deviation, emphysema
Management: position, high 02, 02 sat monitoring, physiotherapy, nebulisers
Circulation management
Problems: sepsis, dehydration, blood loss, drugs, electrolyte abnormalities, ischaemia, MI
Look: colour, haemorrhage, fluid balance, infection, IV access
Listen: BP
Feel: pulse, temperature, cap refill
Management: patent IV access Appropriate bloods Blood cultures Iv fluid bolus 500mls over 5-10mins Assess response Catheterisation
Disability management
Problems: brain injury, infection, lesions, epilepsy, hypoxia, intoxication, cardiovascular, metabolic
Look, listen, feel: conscious level AVPU/GCS, drowsiness, lethargy, blood glucose, pupil size and reaction, seizures, assess pain
Management: recovery position, blood glucose, control seizures, manage pain, GCS
Exposure management
Head to toes assessment
Look listen feel: rashes, surgical wounds, drains, stoma, abdominal distension, haemorrhage, infection, redness, swelling
On completion of assessment
Review documentation: obvs chart, track and trigger score, fluid balance charts, drug prescriptions, case notes,
Systems review
Management plan
Communicate with MDT using SBAR Consider human factors Document management plan Review patient progress Further investigations Involve senior help early Consider referral to other specialties
Met call criteria
Airway: threatened
Breathing: resps under 8 over 30
Circulation: pulse under 40 over 130, systolic less than 90
Neuro: greater than 2 point fall in GCS, repeated or prolonged seizures
Urine output: fall to less than 100ml over 3 hrs
Pulse oximetry: O2 less than 90% despite O2 administration
Calling a MET call
Page the relevant registar
Code blue dial 55 in no urgent of after hours
State medical emergency, ward, room number,
Benefits: reduces incidence of cardiac arrest up to 60%
Reduces crit care admissions
Reduces number of bad days
Reduces hospital mortality
