This document provides an overview of several common critical medical conditions including respiratory failure, ARDS, acute MI, CHF, GI bleed, DKA, shock, and sepsis. It defines each condition and discusses signs and symptoms, causes, complications, treatments, and nursing interventions. Respiratory failure can result from ventilation-perfusion mismatching or intrapulmonary shunting. ARDS causes damage to the alveolar-capillary interface leading to pulmonary edema. Acute MI is caused by coronary artery obstruction from thrombus or plaque. CHF occurs when the heart cannot pump sufficient blood to meet metabolic needs.

1. “ Never let what you cannot do interfere with what you can do” CRITICAL CONDITIONS Sherry L. Knowles, RN, CCRN, CRNI

2. OBJECTIVES Recognize the signs & symptoms of several common (critical) medical conditions. Describe the current treatment modalities of those common (critical) medical conditions. Discuss the overall management of select (critical) medical conditions. Identify the nursing interventions of several common (critical) medical conditions. CRITICAL CONDITIONS

3. Respiratory Failure ARDS Acute MI CHF CRITICAL CONDITIONS GI Bleed DKA Shock Sepsis

4. DEFINITION A respiratory system that fails to maintain adequate gas exchange. Acute loss of adequate oxygenation at the tissue level. PaO 2 < 60 mmHg and/or PaCO 2 > 50 mmHg @ 21% FiO 2 In chronic hypercapnia: pH < 7.35 Respiratory failure may be evidenced by a high or low pCO2 level. RESPIRATORY FAILURE

5. TYPES OF FAILURE Hypercapnic Respiratory Failure is ineffective ventilation (increased PaCO 2 ), with normal oxygenation (normal alveolar-arterial O2 gradient). Hypoxemic Respiratory Failure is characterized by low PaO 2 , markedly elevated P(A-a)O 2 gradient, and usually low PaCO 2 , reflecting adequate ventilation, but inadequate gas exchange. RESPIRATORY FAILURE

6. SIGNS & SYMPTOMS Neurological Restlessness, Agitation, Headache Disorientation, Seizures,  LOC Cardiovascular  Heart Rate, Hypertension (early), Hypotension (late), Chest Pain , Dysrhythmias Respiratory  Respirations,  Respiratory Effort RESPIRATORY FAILURE

7. CAUSES V/Q Mismatch Ventilation / Perfusion Mismatch  V/Q ratio =  ventilation to perfusion Intrapulmonary Shunt Perfusion without ventilation Cardiac Failure May result in pulmonary congestion RESPIRATORY FAILURE

8. SIGNS & SYMPTOMS Renal  UOP, Edema Gastrointestinal  Bowel Sounds, Nausea/Vomiting, Abd Distention, Bleeding Integumentary Cool, clammy, pale skin, Decreased Capillary Refill RESPIRATORY FAILURE

9. TREATMENT Protect the Airway Intubation (if needed) Bronchodilators Hydration (as appropriate) Mucolytic (if appropriate) RESPIRATORY FAILURE

10. TREATMENT Correct the Acid-Base Imbalance ABG’s Bronchodilators Mechanical or non-invasive ventilation Treat the Cause Reduce sedation Add sedation Bring fever down RESPIRATORY FAILURE

11. TREATMENT  FiO 2 Ineffective with shunting Prolonged O2 > 40% may cause O2 toxicity (lung damage) Must use caution with CO2 retainers Chronic hypercapnia causes CO2 retainers to use hypoxic (O 2 ) drive Too much O2 can depress respirations RESPIRATORY FAILURE

12. NURSING INTERVENTIONS Monitor the Patient Monitor ABG’s Monitor respiratory status Monitor response to therapies Report Changes Watch for improvement Keep respiratory status well documented Treat Causes Antibiotics Diuretics Mucolytics RESPIRATORY FAILURE

13. DEFINITION Syndrome that causes damage to the alveolar-capillary interface. Causes an acute lung injury that causes  pulmonary capillary permeability and alveolar flooding. Characterized by non-cardiogenic pulmonary edema, respiratory distress, and hypoxemia. ARDS

14. CAUSES Aspiration Injuries Sepsis Multiple Blood Transfusions DIC Shock States Severe Pancreatitis Embolism ARDS

15. SIGNS & SYMPTOMS Dyspnea Low Pa O2 Intrapulmonary Shunting Low Pa O2 despite high FiO 2 Pulmonary Crackles Diffuse bilateral alveolar infiltrates Low or normal PAWP ARDS

16. SIGNS & SYMPTOMS Early Irritability, confusion, hyperventilation, tachypnea, dyspnea, tachycardia Late Increasing respiratory insufficiency,  pulmonary compliance (  pulmonary vascular resistance), PCO 2 retention, frothy sputum, pulmonary crackles ARDS

17. COMPLICATIONS Barotrauma Pulmonary Fibrosis Pulmonary Emboli  Cardiac Output Renal Failure Nosocomial Pneumonia Sepsis DIC ARDS

18. TREATMENT Maintain Oxygenation BiPAP, CPAP Intubation PEEP ABG Monitoring Maintain Vascular Volume IVF Fluid Restriction Treat the Cause Antibiotics ARDS

19. DEFINITION Infarction occurs due to mechanical obstruction of a coronary artery (or branch) caused by a thrombus, plaque rupture, coronary spasm and/or dissection. ACUTE MI

20. SIGNS & SYMPTOMS Complains vary and may include crushing chest pain (which may or may not radiate), back, neck, jaw, teeth and/or epigastric pain, nausea/vomiting and dizziness. ST elevations on ECG Elevated cardiac enzymes ACUTE MI

21. SIGNS & SYMPTOMS  PAWP,  CO,  SVR, dysrhythmias, S 4 , cardiac failure, cardiogenic shock Diaphoresis, pallor, referred pains Diabetics and women often present abnormal symptoms ACUTE MI

22. COMPLICATIONS Dysrhythmias, heart failure, pericarditis, ventricular aneurysms, ventricular thrombus, VSD, mitral regurgitation, papillary muscle (or chordae tendineae) rupture, pericardial effusions, pericarditis ACUTE MI

23. TREATMENT Time Is Heart Muscle The goal of treatment for an AMI is to relieve pain, limit the size of the infarction and to prevent complications, primarily lethal dysrhythmias Prompt ECG ACUTE MI

24. TREATMENT Usual medications include O 2 , NTG, MSO 4 , aspirin, heparin, beta-blockers, and ace inhibitors. May also include thrombolytics or Gp2a3b inhibitors Cardiac Catheterization (with angioplasty, atherectomy and/or stent) IABP, CABG, Education ACUTE MI

25. TREATMENT IWMI Fluids Inotropics Afterload reducing medications AWMI Diuretics Inotropics Afterload reducing medications ACUTE MI

26. NURSING INTERVENTIONS O 2 Bedrest Serial ECG’s Serial cardiac enzymes Keep pain free (NTG. MSO 4 ) Aspirin, heparin, beta-blockers, ace inhibitors, Gp2a3b inhibitors, thrombolytics, PTCA, IABP, CABG ACUTE MI

27. DEFINITION CHF A condition in which the heart cannot pump sufficient blood to meet the metabolic needs of the body. Pulmonary (LVF) and/or systemic (RVF) congestion is present. CHF

28. DEFINITION Pulmonary Edema Fluid in the alveolus that impairs gas exchange by altering the diffusion between alveolus and capillary; acute left ventricular failure causes cardiogenic pulmonary edema. Non-cardiogenic pulmonary edema is a synonym for Adult Respiratory Distress Syndrome (ARDS). CHF

29. SIGNS & SYMPTOMS Sympaththetic nervous system stimulation Tachycardia Vasoconstriction and increased SVR Renin-angiotensin-aldosterone system activation Hypo perfusion to the kidneys (rennin) Vasoconstriction (angiotension) Sodium and water retention (kidneys) Ventricular dilation See Handout CHF

30. FUNCTIONAL CLASSIFICATIONS Class I Class II Class III Class IV CHF

31. COMPLICATIONS Respiratory Failure Dysrhythmias Hypotension Progressive Deterioration Acute Renal Failure Fluid & Electrolyte Imbalances CHF

32. TREATMENT Improve Oxygenation Decrease Myocardial Oxygen Demand Decrease Preload Decrease Afterload Increase Contractility Manage Dysrhythmias CHF

33. CAUSES PUD Stress Ulcers Esophageal Varicies Portal Hypertension Mallory Weiss Syndrome GI BLEED

34. SIGNS & SYMPTOMS Hematemesis Hematochezia  BP  H & H  BUN Weakness Dizziness Syncope GI BLEED

35. TREATMENT Hemodynamic Stabilization Blood, IVF, NGT, antacids, H 2 blockers, antibiotics, serial H & H’s and clotting factors Vasopressin (Pitressin) Sengstaken-Blakemore or Minnesota Tube Sclerotherapy Laser Electorcautery Surgery GI BLEED

36. NURSING INTERVENTIONS Large Bore IV’s Type & Cross Match Blood Serial H & H’s (q4hr) Monitor Clotting Factors Watch for Complications ARF, ARDS, DIC Maintain Tubes NG, Blakemore or Minnesota Tube GI BLEED

37. DEFINITION Serious or life-threatening complication usually from diabetes mellitus type I. Results from relative or absolute insulin deficiency. DKA

38. CAUSES Type I DM Insufficient Insulin Dosing Poor Compliance Malfunctioning Insulin Pump Phenytoin (Dilantin) Thiazide/Sulfonamide Diuretics Stress New Onset DM DKA

39. SIGNS & SYMPTOMS Sudden Onset (hours) Serum Glucose 300-800 Ketones Strongly Positive Serum pH < 7.3 (Ketoacidosis) Fruity Acetone Breath (Ketones) Kussmaul Respirations Serum Osmolarity < 350 DKA

40. SIGNS & SYMPTOMS Thirst (polydipsia) Dry Mouth Dry Skin Weakness Kussmaul Respirations Polyuria DKA Hypotension Tachycardia Mental confusion Changes in LOC Mental confusion Changes in LOC

41. TREATMENT Reverse Dehydration Rapid IVF Replacement NS, then ½ NS Continue NS If Needed Prevent Hypoglycemia D5½ NS when Glu 250 DKA

42. TREATMENT Restore Normal Glucose Levels Give Rapid Acting Insulin Frequent Glu Monitoring (q ½ - 1 hr) Monitor Serum and Urine Ketones DKA

43. TREATMENT Replenish Electrolytes Watch for Dilution Monitor Electrolytes Frequently Insulin Lowers Serum K DKA

44. ADDITIONAL INTERVENTIONS Monitor Frequent Accuchecks (q1hr) Monitor Serial Serum Glucose (q4hr) Monitor Serial Electrolytes (4hr) Monitor Anion Gap (q4hr) Monitor Serum & Urine Ketones DKA

45. DEFINITION Inadequate perfusion to the body tissues Low blood pressure with impaired perfusion to the end organs May result in multiple organ dysfunction SHOCK

46. TYPES OF SHOCK Hypovolemic Shock Cardiogenic Shock Distributive Shock Obstructive Shock SHOCK

47. SIGNS & SYMPTOMS The body attempts to compensate for shock: Tachycardia Attempts to deliver more blood to the tissues Vasoconstriction Attempts to maintain adequate BP in order to adequately perfuse the body tissues Increased ADH Secretion ADH makes the body hold onto water in an effort to maintain volume and thus enough blood pressure to perfuse the body tissues SHOCK

48. SIGNS & SYMPTOMS Hypovolemic Shock: Low BP , tachycardia, orthostatic hypotension, restlessness, confusion, agitation (or listless), thirst, pallor, cool, clammy skin,  resp. rate,  UOP,  CO,  PAWP,  CVP,  SVR,  lactate levels SHOCK

49. SIGNS & SYMPTOMS Cardiogenic Shock: Low BP , tachycardia, restlessness, confusion, agitation (or listless), thirst, pallor, cool, clammy skin,  resp. rate,  UOP,  CO,  PAWP (low with RVF),  CVP,  SVR, JVD, peripheral edema, ventricular gallop, dyspnea, pulmonary crackles,  lactate levels SHOCK

50. SIGNS & SYMPTOMS Anaphylactic Shock: Low BP , tachycardia, orthostatic hypotension, restlessness, confusion, agitation (or listless), thirst, pallor, warm feeling, pruritus, hives, angioedema, bronchoconstriction, wheezing, laryngoedema, dyspnea, cool, clammy skin,  UOP,  CO,  PAWP,  CVP,  SVR,  lactate levels SHOCK

51. SIGNS & SYMPTOMS Obstructive Shock: Low BP, tachycardia, restlessness, confusion, agitation (or listless), pallor, cool, clammy skin,  UOP,  CO, symptoms related to cause SHOCK

52. SIGNS & SYMPTOMS Septic Shock: Early Stage (Hyper-dynamic, Warm Phase) Normal BP, tachycardia, confusion, agitation (or listless),  resp. rate,  temp, normal color, normal or  UOP,  CO, normal PAWP,  CO,  SVR,  SHOCK

53. SIGNS & SYMPTOMS Septic Shock: Late Stage (Hypo-dynamic, Cold Phase) Low BP, tachycardia, orthostatic hypotension, restlessness, confusion, agitation (or listless), thirst, pallor, cool, clammy skin,  UOP,  CO,  PAWP,  CVP,  SVR,  lactate levels SHOCK

54. TREATMENTS Hypovolemic Shock: Volume (IVF, Blood) Cardiogenic Shock:  CO  Preload & Afterload  Myocardial Demand SHOCK

55. TREATMENTS Anaphylactic Shock: Epinephrine IVF Vasoconstrictors Support/Maintain Airway Obstructive Shock: Treat the Cause SHOCK

56. TREATMENTS Septic Shock: IVF (150cc/hr or wide open) Treat Cause (pan culture, antibiotics) Vasoconstrictors in warm phase Treat temp if needed SHOCK

57. DEFINITION SIRS Systemic Inflammatory Response Manifested by two or more of the following: Temp > 38C or < 36C, HR > 90/min, RR > 20/min, CO2 < 32 mmHg, WBC > 12,000 or < 4,000 or > 10% (immature) bands Sepsis Inadequate perfusion to the body tissues due to bacteremia. SEPSIS

58. DEFINITION Severe Sepsis Sepsis associated with organ dysfunction, hypo-perfusion or hypotension. Septic Shock Systemic response to infection. SEPSIS

59. SIGNS & SYMPTOMS Early Stage (Hyper-dynamic, Warm Phase) Normal BP, tachycardia, confusion, agitation (or listless),  resp. rate,  temp, normal color, normal or  UOP,  CO, normal PAWP,  CO,  SVR,  SEPSIS

60. SIGNS & SYMPTOMS Late Stage (Hypo-dynamic, Cold Phase) Low BP, tachycardia, orthostatic hypotension, restlessness, confusion, agitation (or listless), thirst, pallor, cool, clammy skin,  UOP,  CO,  PAWP,  CVP,  SVR,  lactate levels SEPSIS

61. COMPLICATIONS Acute Renal Failure Multiple Organ Failure Disseminated Intravascular Coagulation Death SEPSIS

62. TREATMENT Give IVF (150cc/hr or wide open) Treat the Cause (Pan culture, antibiotics,) Give Vasoconstrictors in warm phase (vasoconstrictors are contraindicated in cold phase). Treat Temperature as needed Consider Protein Activated C (Xigris) SEPSIS

63. THE END CRITICAL CONDITIONS

64. THANK YOU CRITICAL CONDITIONS

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