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Critical Care

Terms in this set (38)

Why is a Ventilator needed?
-Respiratory failure

-ARDS: Acute resp distress syndrome
Sudden resp failure

-Severe SOB, hypoxemia refractorary to O2, decreased lung compliance, diffuse pulm infiltrates, sepsis

-Mortality 50%, common cause: sepsis
ARDS: Acute resp distress syndrome
Ventilator
Prone positioning
Hemodynamic monitoring
Enteral feedings
Fluid balance
New therapies
Intubation
1. Orally or nasally with an endotracheal tube (ETT)
2. Bag-valve-mask (ambu)
3. Confirm placement
4. Cuff inflation
5. Tube patency: closed suction
6. Oral care
7. Communication

•Check for bilateral chest expansion and breath sounds to make sure it isn't just in one lung. Once placement is confirmed, tape the tube and get the measurement so you can see if it gets moved at all. Check carbon dioxide to make sure you are not in the stomach. CO2 detector is the BEST way to determine if the tube is in the lungs and not the stomach. An XRAY will tell you where at it is in the lungs and if it needs to be adjusted.

•Ventillators have closed suction system so you don't have to worry about how long can you suction someone because you just shove it down and pull it out.

•DO NOT PUT SALINE DOWN BEFORE YOU SUCTION! (called lavaging)

•Oral care is important! If you leave all that bad bacteria/secretions in their mouth, they are at risk for getting VAP.
Ventilator Settings
Assist Control (AC) or Synchronized Intermittent Mandatory Ventilation (SMIV)
Respiration rate
FiO2
Tidal volume
Pressure support or PEEP
Ventilator Orders
•Continuous O2 sat/nebulizer tx
•Analgesia/sedatives
•PCXR daily (portable chest xray)
•ABGs
•DVT (heparin) and GI prophylaxis (at risk for an ulcer - give reglan, protonix)
•Bowel regime/foley (check I&O)
•NPO/ NGTube
Ventilator Associated Pneumonia (VAP)
•Pneumonia that occurs 48 hours or more after intubation

•Prevention: HOB 30-45°, good mouth care, continuous suctioning of secretions, handwashing
Extubating
Have O2 set up, have suction set up. The physician will deflate the balloon then pull out the tube. Then give them the oxygen mast. Monitor closely and take all vitals. See how they do without the ventilator. Give ice chips.
Myocardial Ischemia (MI) Medications
Oxygen
ASA
Nitrates
Morphine
(MONA)
Beta Blockers
Ca channel blockers
ACE inhibitors
Heparin/ Lovenox/ Fragmin
TPA (Tissue plasminogen activator)
Myocardial Revascularization
•Fibrinolytics: for ST elevation MI,
w/i 6 hours, bleeding risk,
ex. TPA, Retavase, Streptokinase
•Percutaneous Transluminal Coronary Angioplasty (PTCA)
•Coronary Atherectomy
•Coronary Artery Bypass Grafting (CABG)
•Time is muscle (try and get to cath lab within 90 minutes)
•Angioplasty with stent
•Direct Thrombin Inhibitors: Angiomax, Refludan, and Argatroban
Percutaneous Transluminal Coronary Angioplasty (PTCA)
Stents
•Mesh that holds vessel open
•Drug eluding stents
•Glycoprotein IIb/IIIA inhibitor: Integrilin, ReoPro or Aggrastat
•ASA, Ticlid or Plavix
Coronary Atherectomy
-Removal of atherosclerotic plaque
*angioplasty compresses atherosclerotic plaque, atherectomy actually removes it
*pt has to be candidate for PTCA and CABG and sign consent

-Specially designed catheter that shaves the plaque --------- theoretically can leave a nl size lumen and smooth vessel wall; tissue and fibrous plaques are captured in end of cath.

-Nursing care similar to PTCA

-Limitations: thrombotic or highly calcified lesions, distal lesions or tortuous vessels
Coronary bypass grafting (CABG)
-Construction of new vessels to transport blood beyond obstructed coronary artery

-Sternotomy, coronary bypass machine

-Graft from internal mammary artery, saphenous vein, radial or gastric artery

-Not a cure for CAD

-Minimally invasive direct CABG (MIDCABG): off pump

-Criteria for pt selection:
1. chronic angina unresponsive to medical therapy
2. preinfarction angina inresponsive to med. tx
3. triple vessel disease

-Emergency CABG - evolving MI less than 6 hours where thrombolytic and PTCA have been unsuccessful

-Preferable over PTCA or atherectomy in distal lesions

-Increasingly common for elderly pat. to undergo bypass - increased risk of operative mortality

- hi risk: severe CHF, cardiomegaly, hi left-vent end diastolic pressure, inadequate ejection fraction (EF 20-25% - inoperable)
CABG Complications
Infection
Stroke
ARDS
Pneumonia
Renal failure
Atrial fibrillation
Postoperative nursing management:
-In special post heart ICU

-Aline, swan, monitor, epicardial pacer, ventilator, chest tubes, IABP, IV fluids, sedation and pain meds, surgical site assessment
Nursing diagnoses
Hypothermia
Pain
Ineffective breathing pattern/impaired gas exchange
Risk for infection
Risk for altered tissue perfusion
Altered thought processes
Sternal Precautions
-No pushing or pulling
-No reaching over head or behind back
-No lifting> 10 lbs.
-Use pillow for splinting
-Check for sternal instability
Arterial Lines
•Continuous blood pressure monitoring

•Via artery: usually radial

•Allen's test

•Blood access: labs and ABGs

•Indications: Hypotension, hypertension, resp failure, shock, during surgery, admin of vasoactive drugs

•Risks: Hemorrhage, infection, thrombus, NV impairment, vascular changes in fingers
Intraaortic Balloon Pump
•Indications: acute MI, cardiogenic shock, cardiac surgery

•Reduces afterload

•Counterpulsation because timing of balloon inflation is opposite of ventricular contraction

•During systole the balloon is deflated so blood can be injected into the periphery. In diastole balloon inflates which augments aortic pressure and increases coronary blood flow

-For very sick patients whove had MI's and are in cardiogenic shock. Goes opposite of what the patient is doing to keep everything open and perfusing.
Intraaortic Balloon Pump (IABP)
Ventricular Assist Device (VAD)
•Long term temporary support for failing heart
•Indications: post MI, awaiting heart transplant
•Augment or replace action of ventricle
Left Ventricular Assist Device
Implantable Cardiac Defibrillator ( ICD)
•Internal defibrillator and pacemaker

•Treatment of malignant ventricular arrhythmias

•Indications: cardiac arrest survivors, sustained VTACH, risk of sudden death

•Shock directly to heart muscle
Heart Transplants
•Indications: End stage cardiac disease, inoperable CAD, suitable age, compliance, emotional stability and support

•Transplant wait list

•Risks: acute rejection and infection

•Artificial heart with external battery pack
Shock
•Inadequate blood flow through the tissues

•Clinical syndrome characterized by a systemic imbalance between supply & demand, state of inadequate blood flow to peripheral tissues, causing life-threatening cellular dysfunction, hypotension, and oliguria
The Common Denominator of Shock
Shock Stages
1. Compensatory Stage
2. Progressive Stage
3. Refractory Stage
Compensatory Stage:
•Decreased CO
•Hypotension
•Blood flow to brain and heart maintained •Low blood flow to kidneys, GI tract, lungs, and skin
Progressive Stage:
•Compensatory Mechanisms fail

•Interstitial fluid increases (anasarca)

•Tachypnea, rales, hypotension, change in mental status, dysrhythmias, MI, oliguria, ATN, acute renal failure, ulcers, GI bleed, liver failure, DIC
Refractory Stage
•Decreased perfusion from vasoconstriction and decreased CO

•Profound hypotension and hypoxia

•Organ failure of liver, lungs, and kidneys

•Recovery unlikely
Hypovolmic Shock
•Absolute:
-Loss of blood
-Loss of other body fluids

•Relative:
-Pooling of blood or fluids
-Fluid shift
-Internal bleeding
-Vasodilation

•Pt response:
-  HR, RR, anxiety, ↓CO, ↓ UO
Cardiogenic Shock
•Occurs when poor pumping function results in decreased CO
-d/t MI, cardiomyopathies, blunt cardiac injury, severe HTN, myocardial depression

•Occurs when ventricles unable to fill
-d/t cardiac tamponade and cardiomyopathy

•Patient response:
-Tachycardia, hypotension, narrowed pulse pressure, rales, cyanosis, pallor, cool clammy skin, ↓ UO, anxiety, confusion, agitation
Septic Shock
•Systemic inflammatory response to an infection

•Caused by: gm negative and positive bacteria, also parasites, fungi, viruses

•At risk patients: old, chronic disease, malnourished, debilitated

•Pt response: hypotension, fever or hypothermia, edema, hyperglycemia, HR and RR decreased, Δ mental status, resp failure, ARDS
Anaphylactic Shock
•Wide spread hypersensitivity reaction

•Causes: contrast media, blood, drugs, insect bites, food, food additives, anesthesia, vaccines, environmental agents, latex

•Pt response: resp distress, bronchospasm, dizziness, CP, incontinence, swelling of lips and tongue, wheezing, stridor, flushing, uticaria, pruritis, anxiety, confusion, feeling of doom
Neurogenic Shock
•w/i 30 minutes of spinal injury

•Massive vasodilation and hypoperfusion

•Hypotension and bradycardia

•Inability to regulate temperature
Poikilothermia


•Results from an imbalance between parasympathetic and sympathetic stimulation of vascular smooth muscle --> vasodilation, pooling of blood
-Head injury, spinal cord trauma, severe pain, spinal anesthesia
Shock: Nursing Management
•Assessment: swan, aline or NBP, IV access, foley, watch MAP

•Interventions:
-Oxygen therapy/vent
-Nutrition: daily wts
-Intra aortic balloon pump (IABP) or VAD
increased coronary perfusion, decreased afterload, decreased cardiac workload
•Fluid Resusitation
-Corticosteroids
-Colloids
*Hetastarch
*5% Albumin
*PRBCs and FFP
-Crystalloids
Medications in Shock
•Sympathomimetics
-Dopamine
-Dobutamine

•Adrenergic Agonists
-Epinephrine/Vasopressin
-Norepinephrine(Levophed)
-Neo-synephrine

•Direutics (fluid overload)

•Vasodilators
-Nitroprusside
-Nitroglycerin

•Antibiotics, blood glucose control (septic shock)

•Benadryl and epinephrine (anaphylactic)

•Solumedrol (spinal cord injury)
SIRS and MODS
•Systemic Inflammatory Response Syndrome to an insult: infection, ischemia, infarction, and injury

•Can result in MODS (multiple organ dysfunction syndrome) failure of 2 or more organ systems
-Resp system
-Cardiac
-Neuro
-Renal
-GI
-DIC
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