The Critically iil patient; Basic concepts.pptx

Powerpoint

1. The Critically Ill Patient: Basic Concepts Medical Surgical Nursing 111 F. NHLANE 2020

2. Learning objectives Define the terms: Critical illness and critical care Describe the 3 main categories in the management of the critically ill patients

3. Definition of terms Critical Illness Is a life-threatening multisystem illness that can result in significant morbidity or mortality. Critical care Also termed ` intensive care` Specialized care of patients whose conditions are life-threatening and who require comprehensive care and constant monitoring

4. Overview of critical illness and critical care Care of the critically ill patients require a multidisciplinary approach Initial aspects of care of the critically ill patients include: Resuscitation( Airway, Breathing, Circulation) Stabilization Monitoring After ABC…, are under control, patient`s condition is described as stabilized which must be maintained through close monitoring in the areas of: Hemodynamic and cardiopulmonary functionality

5. Categories in the management of patients in the ICU setting 3 main categories: Ventilatory and hemodynamic support Treatment of specific illnesses Preventive care

6. Ventilatory & Hemodynamic support Respiratory and CVS failures are common reasons for admissions in ICU Monitoring of respiratory & CVS functionality are typical procedures of ICU routine Such procedures are quite complex and complicated requiring various understanding of: Monitoring Principles Monitoring devices Monitoring techniques Interpretation of findings Nursing interventions

7. Monitoring Respiratory functioning Respiratory failure is the most common cause of ICU admission ICU nurse must understand: physiology & pathophysiology of respiratory system; variety of parameters/monitors used to evaluate respiratory status; Why? in order to make decisions about pulmonary function and gas exchange

8. Available respiratory monitoring techniques Key aspects: Technical functionality & clinical application Physical examination Most basic technique Often under-estimated Provides first clue that something is wrong Utilizes traditional techniques of inspection, auscultation, palpation, percussion

9. Physical examination CTs Provides on going assessment of respiratory function especially when used with other monitoring tools Apparently, these physical signs do not provide adequate/timely warning signs and do not change quickly to confirm intervention was appropriate. Chest X-Rays Provides data about lung pathology Not timely Requires knowledge/skill to inteprate.

10. Available respiratory monitoring techniques Arterial Blood Gas Analysis Monitors blood gas exchange Most important indicator of respiratory monitoring system Provides a measure of PaO2, PaCO2, pH, HCO3 and SaO2 These parameters define adequacy of gas exchange & acid base balance and overall cardiopulmonary status Challenges: Invasive procedure Unavailability of blood gas analyzers

11. CT’ The key components to an ABG are: pH - This measures the balance of acids and bases in the blood. Partial pressure of oxygen (PaO2) - This measures the pressure of oxygen dissolved in the blood. Partial pressure of carbon dioxide (PaCO2) - This measures the amount of carbon dioxide in the blood and how well carbon dioxide can move out of the body.

12. Ct’ Bicarbonate (HCO3) - This is calculated using the measured values of pH and PaCO2 to determine the amount of the basic compound made from carbon dioxide (CO2.) Oxygen saturation (O2 Sat) - This measures how much hemoglobin in your blood is carrying oxygen.

13. Ct’ Oxygen content (O2CT) - This measures the amount of oxygen in your blood. Hemoglobin - This measures the amount of hemoglobin in your blood.

14. Normative Values According to the National Institute of Health, typical normal values are: pH: 7.35-7.45 Partial pressure of oxygen (PaO2): 75 to 100 mmHg Partial pressure of carbon dioxide (PaCO2): 35-45 mmHg Bicarbonate (HCO3): 22-26 mEq /L Oxygen saturation (O2 Sat): 95-100%

15. Ct’         [5]

16. Interpretation Look at the pH Increased = Alkalosis Decreased = Acidosis Look at the PaCO2 Increased = Respiratory Acidosis Decreased = Respiratory Alkalosis Look at the HCO3 Increased = Metabolic Alkalosis Decreased = Metabolic Acidosis

17. Ct’ The results should always be read and compared in reference to the patients previous ABG (if available) as you will then be able to assess a trend and make a more accurate assessment on whether you should treat or if your treatment has be successful or not.

18. Respiratory monitoring techniques Ct.., Pulse Oximetry (SpO2) Routine monitoring of O2 status at tissue level Non-invasive & timely Capnography (end tidal CO2) Monitors of ventilation Non invasive measurement of CO2 at the end of exhalation graphically presented on some models of ventilators

19. Monitors of respiratory function in the mechanically ventilated patients There are a variety of measurements that evaluate respiratory function in the mechanically ventilated patients Such measurements are displayed on the air way pressure gauge manometers;(ventilation equipment used to monitor the patients` airway pressure); of different models of mechanical ventilators; Some are obtained through calculations of the available/recordable pressures

20. Monitors of airway pressure CTs….., Examples include: Dynamic Compliance (Cdyn): this reflect pressure necessary to overcome airway resistance and compliance in the lungs and chest wall Static compliance( Cstat ); Pulmonary compliance during period without gas flow PEEP: Positive end expiratory pressure: Pressure in the lungs (alveolar pressure) above atmospheric pressure that exists at the end of expiration

21. Summary of respiratory monitoring A variety of monitors are available and used to evaluate respiratory function Selection depends on understanding of the technique and interpretation of the data in relation to the disease and management. Information can only be useful if collected by reliable equipment and interpreted in the light of physical examination

22. Hemodynamic Monitoring Continuous monitoring of the movement of blood and the pressures being exerted in the veins, arteries, and chambers of the heart Specialized methods of evaluation of cardio-respiratory performance Can be done invasively or non-invasively or derived

23. Hemodynamic Monitoring CT…, Non-invasively: no device inserted into the body; HR, B/P, urine output(no breach of body surface) Invasive pressure monitoring: (Probes introduced into the body) requires the insertion of a catheter into an artery; Derived: Calculated from primary measurements

24. Purpose of hemodynamic monitoring Provides information about: Tissue performance Blood volume Cardiac performance Tissue oxygenation Vascular tone

25. Importance of hemodynamic measurements To establish a precise health related diagnosis To determine appropriate therapy To monitor response to therapy

26. common monitoring technologies Systemic arterial pressure monitoring: Measuring pressure invasively by penetrating the arterial wall eg Arterial Lines (A-lines)ABP Thin catheter inserted into an artery Can be inserted into radial, brachial, femoral arteries Indications: Used to monitor B/P(ABP) Convenient for blood sampling; can get blood samples

27. Complications of A-lines Failure to obtain readings if kinked Thrombosis Embolism Bacterial contamination

28. common monitoring technologies CTs Central Venous Pressure (CVP) Achieved by passing a central venous catheter into any of the large veins; the tip of the catheter rests on the lower third of the superior vena cava. Reflects amount of blood returning to the heart and ability of the heart to pump blood Gives an indication of fluid status

29. CVP CT…., Indications Measuring Pressure in the right atrium Indicated whenever fluid volume status is questionable Drug administration Removal of air in the right atrium in air embolism Later insertion of pulmonary artery Complications : Perforation of right atrium, air embolism, internal jugular puncture.

30. CVP ct ’ Normal CVP ranges from 5 to 10 cmH2O The 2 methods used to measure it includes Manometer system, intermittent readings Transducer system, continuous reading displayed on a monitor

31. common monitoring technologies CT.., Pulmonary artery catheter Involves insertion of a catheter into pulmonary artery (internal jugular to rt atrium to rt ventricle to the pulmonary artery) Indications Measuring PAP Derive other parameters eg CI;(cardiac index), SVR Complications: Direct trauma eg cardiac perforation, infections like endocarditis

32. common monitoring technologies CT Non-invasive B/P monitoring ; presents as NIBP

33. 2.Treatment of specific illnesses Involves rightful delivery of prescribed medical therapy without shortcuts (5 rights ) Due to availability of several tubings attached to patients; be cautious of accidental injections: label extension tubes, watch for clots & air bubbles in the lines, keep stopcocks clamped PRN,

34. 3.Preventive Care In ICU Settings Care rendered to stabilized critically ill patients in ICU settings Intended to maximize therapeutic interventions and promote patient safety Management of some complex probes may become a problem even with protocols/checklist developed following research in ICU settings FAST HUG is yet another guide being utilized to provide quality safe care in ICU settings

35. FAST HUG CONCEPT IN ICU SETTINGS MNEMONIC to guide health service delivery; Initially devised by Jean, Lewis Vicent (? Yr ) A means of identifying & checking some key aspects in the general care of critically ill patients Ensures that 7 essential aspects of patient care are not forgotten NOTE FAST HUG may not apply to all ICU patients Does not cover all aspects of patient care

36. Key Elements of the FAST HUG CONCEPT Element Importance Consideration F eeding Malnutrition can compromise Initiate feeds as soon as immune function and derail patients stabilizes. recovery Fluids To restore intravascular volume strict input and output monitoring in patients hence maintain hemodynamic status A nalgesia Key for comfort of the critica lly ill patient Provide adequate analgesia

37. Key Elements of the FAST HUG CONCEPT CT…, Element Importance Consideration S edation Reduces stress Keep critically ill patients calmed T hromboemboli tic prophylaxis ICU pts at risk for VTE Initiate appropriate prophylaxis H ead of bed To reduce GIT Keep head of bed elevated prn reflux elevated

38. Key Elements of the FAST HUG CONCEPT Element Importance Consideration Stress U lcers Stress ulcers a risk. Prevent Prophylaxis G lycemic control. Compromised. Monitor BS regularly Note FAST HUG not necessarily to be vocalized, but used as a mental checklist when caring for ICU patients

39. Conclusion ICUs are designated for critically ill patients Cardiopulmonary compromise being common reasons for ICU admissions Care in ICU is centered on resuscitation, stabilization, and monitoring Key management strategies in ICU include cardiopulmonary monitoring, treatment of the underlying pathologies and preventive care