CRITICAL CARE NURSING MODULE FOR NURSES.pptx

Critical Care Nursing
• As the specialty that manages human responses to
actual or potential life-threatening problems.
• Is the field of nursing with a focus on the utmost
care of the critically or unstable patients
following extensive injury, surgery or life-
threatening diseases.
• Or intensive care unit (ICU) nursing, is a specialty
focused on the care of unstable, chronically ill or
post-surgical patients and those at risk of life-
threatening diseases.

Conceptual Foundation of Critical
Care
FOCUS:
-Concepts of Critical Care
-Standards of Practice
-Competencies

Concepts
Specialty Practice
Education
Competencies
Experience
Manage, Focus, Care,
Deals
Practice settings where patients
require complex assessment,
high intensity interventions,
and high-level continuous
nursing vigilance
Human Responses
Physiologic and psychosocial
instability, highly vulnerable
unstable and complex
Life-threatening
problems
Conditions that puts the person
in danger of death

COMPETENCIES FOR
CRITICAL CARE NURSES
1. Safe and Quality Nursing Care
2. Management of Resources
3. Legal Responsibilities
4. Ethico-Moral Responsibilities
5. Collaboration and Teamwork
6. Personal and Professional Development
7. Communication
8. Health Education
9. Quality Improvement
10. Research
11. Record Management

Goals and Objectives
• Discuss the etiology and natural history
of common pediatric emergencies:
-Respiratory failure
-Shock
-Trauma
• Recognize the acuity and implement
appropriate emergency management

What we learned in PALS...
• Adult and pediatric etiologies of
cardiopulmonary arrest differ, a different
approach to assessment and intervention is
required in the pediatric population.
• Pediatric cardiopulmonary arrest results
when respiratory failure or shock is not
identified and treated in the early stages.

Etiologies of
Cardiopulmonary Arrest
in Children
• Bronchospasm, Burns, Congenital
cardiac abnormalities, Drowning,
Dysrhythmias, Foreign body aspiration,
Gastroenteritis, Seizures, Sepsis,
Trauma, Upper and lower respiratory
tract infection
• The etiologies of respiratory failure,
shock, cardiopulmonary arrest and
dysrhythmias in children differ from

• Approximately 10 percent of children who
progress to cardiopulmonary arrest are
successfully resuscitated.
• Children who only have respiratory arrest
have a 75 to 93 percent survival rate when
resuscitated.
• 92 percent of such children had no neurologic
impairment .
• Pediatric advanced life support begins with
early recognition and management of
respiratory failure and shock.

How are kids different?
• Cardiac arrest is usually due to
progressive respiratory failure, shock or
both
• Once you have cardiac arrest---
Outcome is poor
-5-12% survive to discharge
-In-hospital not much better with
27% survival

ABCDE Assessment and
treatment Guide

Normal Pediatric Vital Signs by Age

Securing the Airway and
Endotracheal Intubation

Markers of a Successful Sepsis
Resuscitation

Workup for Complex
Febrile Seizure

Pulmonary assessment &
Common Pulmonary
Disorders

History Taking
-Reason for seeking care
-Present illness
-Previous illness
-Family history
-Social history
Physical Examination
-Respiratory Assessment (I-P-P-A)
The Assessment

Chief Complaint
-Cough
-Sputum Production
-Shortness of breath/Dyspnea
-Hemoptysis
-Chest Pain
-Wheezing
History Taking

COUGH
 Onset - sudden, gradual
 Duration
 Nature - dry, moist, hacking, barking
 Sputum - amount, color, odor
 Severity - disrupts activities?
 Associated symptoms - sneezing, dyspnea, fever,
chills, congestion, gagging
 What brings it on? - anxiety, talking, activity
 What makes it better?
 What has been tried? - medications, treatments
 Anything similar in the past

SPUTUM
COLOR POSSIBLE INDICATION
Clear or White Common colds or bronchitis
Yellow or Green Indicates Infection
Rust-colored TB, Pneumococcal pneumonia
Pink-frothy Pulmonary edema
Foul-smelling Abscess or bronchiectasis
Mucopurulent Chronic bronchitis or cystic fibrosis

SHORTNESS OF BREATH OR DYSPNEA
 Onset - sudden, gradual
 Duration
 Severity - disrupts activities
 Associated symptoms - night sweats, pain, chest
pressure, discomfort, ankle edema, diaphoresis, cyanosis
 What brings it on? - position, time of day, exercise,
allergens, emotions
 What makes it better?
 What has been tried? - medications, inhalers, oxygen
 Anything similar in the past?

CHEST PAIN
 PQRST
 Any chest pain with breathing? Please point the
exact location
 When did it start? Constant or does it come and
gо?
 Describe the pain: burning or stabbing?
 Brought on by respiratory infection, coughing or
trauma?
 Is it associated with fever, deep breathing or
unequal chest inflation?
 What have you done to treat it?

History
 Personal and Social History
 Tobacco
 Alcohol
 Drugs
 Home, Occupation or Travel Environment
 Health Promotional Activities
 Wearing of mask, routine checks,
vaccination

Additional History
 Infants and children
 Frequency of cough and/or colds
 History of allergy in the family
 Child-proofing of home
 Smokers in the home or in the car with child
 Aging Adult
 SOB on ADLs
 Routine physical activities
 Coping mechanisms (COPD, PTB, Lung Ca)

Equipment and Techniques
 Equipment
 Stethoscope
 Techniques
 Inspection
 Palpation
 Percussion
 Auscultation

Anterior Thorax
Inspection
 Appearance
- Symmetry, deformities
 Posturing
 Respiratory rate, effort and pattern
 Skin, nails and lips color
Palpation
 Tracheal position
 Chest expansion
Auscultation
 Duration, pitch and intensity of 1 & E sounds
in one breathing cycle
 Normal and Adventitious Sounds

Posterior Thorax
Inspection
 Contour, symmetry and deformity, skin
Palpation
 Areas of tenderness
 Chest expansion
 Tactile fremitus
Percussion - "ladder pattern"
 Diaphragmatic Excursion
Auscultation
 Duration, pitch and intensity of I & E sounds
in one breathing cycle
 Normal and Adventitious Sounds

Inspection
 Altered rhythms may indicate underlying disorder:
 Kussmaul's respirations - rapid, deep with sighing breaths,
occurs in patients with DKA
 Cheyne-Stokes respirations - have a regular cycle of change
in the rate & depth of breathing; periods of deep breathing
alternating with periods of apnea
 Biot's respirations (Ataxic) - unpredictable breaths
irregularity, rapid deep breaths that alternate it abrupt periods
of apnea

Inspection
 Nasal flaring - intermittent outward
movements of the nostrils with each
inspiration
 Pursed-lip breathing - partial closure of
the lips to allow air to be expired slowly
 Retractions - visible indentations between
the ribs as the intercostal muscles aid in
breathing

Inspection
 If retractions are noted, look for the
location of the retractions.
Suprasternal retractions - seen above the
clavicle and sternum
Intercostal retractions - occur between the
ribs
Subcostal retractions - seen below the lower
costal margin of the rib cage
Substernal retractions - seen below the
xiphoid process.

Palpation
 Trachea - slightly movable & quickly returns to
midline after displacement
 Tactile fremitus - transmission of vibration of air
movement through chest wall during phonation
(99 method)
 Chest Expansion - symmetry of chest movement

Tactile (Vocal) Fremitus
 Normal: symmetrical vibrations
bilaterally
 Decreased or absent:
obstruction of transmission
(pneumothorax, emphysema,
pleural effusion)
 Increased ： consolidation
(compression) of lung tissue
(lobar pneumonia)

Assessment of Chest Expansion
 Normal ： bilateral,
symmetric expansion
 Abnormal: unilateral or
unequal (atelectasis, lobar
pneumonia, pleural
effusion, pneumothorax)

Percussion
 Resonant - low-pitched hollow
sound
Normal lung sound
 Hyperresonant - louder & lower-
amount failsence increased
Emphysema
Pneumothorax
 Dull- thudlike; heard over dense
areas such as the heart and liver
Pneumonia
Atelectasis
Tumors

Summary: Adventitious Breath Sounds
Crackles - Air moving through secretions of the small or
middle airways
Wheezes - Air moving through a narrowed or constricted
airway
Rhonchi - Air moving through secretions in the larger
airways
Stridor - Occurs when an upper airway obstruction is
present
Diminished - Heard when there is decreased air movement
in the lungs
Pleural friction rub - When inflamed pleura rub together
due to decreased levels of fluid in the pleural space

Atelectasis
 Inspection:
- Cough
- Lag on expansion on affected side
- Increase RR and PR
- Possible cyanosis
 Palpation:
- Chest expansion decreased on the affected side.
- Tactile fremitus decreased or absent over area.
- With large collapse, tracheal shift towards affected side.
 Percussion:
- Dull over area (remainder of thorax sometimes may have hyperresonant
note)
 Auscultation:
- Breath sounds decreased or absent over area.

Lobar Pneumonia
 Inspection:
- Increased RR;
- Guarding and lag on expansion of affected side.
- Children - sternal retraction, nasal flaring
 Palpation:
- Chest expansion decreased on the affected side.
- Tactile fremitus increased if bronchus patent, decreased if bronchus
obstructed
 Percussion:
- Dull over lobar pneumonia
 Auscultation:
- Breath sounds louder with patent bronchus,
- Children - diminished breath sounds may occur in early pneumonia
 Adventitious Sounds:
 - Crackles, fine to medium

Emphysema
 Inspection:
- Increased AP diameter
- Barrel chest
- Use of accessory muscles to aid respiration,
- Tripod position
- SOB especially on exertion, Respiratory distress, Tachypnea
 Palpation:
- Decreased tactile fremitus and chest expansion
 Percussion:
- Hyperresonant, Decreased diaphragmatic excursion
 Auscultation:
- Decreased breath sounds
- May have prolonged expiration,
- Muffled heart sounds resulting from overdistention of the lungs
- Usually none; occasionally wheezes

Asthma
 Inspection:
- Increased RR
- SOB with audible wheeze
- Use of accessory muscles, cyanosis, apprehension, intercostal
retractions,
- Expiration: labored and prolonged;
 Palpation:
- Decreased tactile fremitus, tachycardia
 Percussion:
- Resonant, maybe hyperresonnant if chronic
 Auscultation:
- Diminished air movement, Diminished breath sounds, with
prolonged expiration.
• Adventitious Sounds:
- Bilateral wheezing on expiration

Pleural Effusion (Fluid) or Thickening
 Inspection:
- Increased respirations, dyspnea;
- may have dry cough, tachycardia, cyanosis and abdominal distention
 Palpation:
- Tactile fremitus decreased or absent;
- Tracheal shift away from affected side.
- Chest expansion decreased on affected side.
 Percussion:
- Dull to flat. No diaphragmatic excursion on affected side
 Auscultation:
- Breath sounds decreased or absent; When remainder of the lung is
compressed near the effusion, may have bronchial breath sounds over the
compression
- None

Pneumothorax
 Inspection:
- Unequal chest expansion,
- If large, tachypnea, cyanosis, apprehension, bulging in interspaces
 Palpation:
- Tactile fremitus decreased or absent.
- Tracheal shift to opposite side (unaffected side).
- Chest expansion decreased on affected side, Tachycardia,
decreased BP
 Percussion:
- Hyperresonnant. Decreased diaphragmatic excursion
 Auscultation:
- Breath sounds decreased or absent
- None

ARDS
 Subjective:
- Acute onset of dyspnea, apprehension
 Inspection:
- Restlessness, disorientation,
- Rapid shallow breathing;
- Productive cough, thin frothy sputum;
- Intercostal and sternal retractions
 Palpation:
- Hypotension
 Auscultation:
- Tachycardia
- Crackles, rhonchi

Steps in ABG Interpretation
Example One:
John Doe is a 55 year-old male admitted to your nursing unit with
recurring bowel obstruction. He has been experiencing intractable
vomiting for the last several hours despite the use of antiemetics. His
arterial blood gas result is as follows: pH 7.50. pCO2 42, HCO, 33.
Step One:
Identify whether the pH, pCO2 and HCO3, are abnormal. For each
component, label it as "normal", "acid" or "alkaline".
The two matching values determine what the problem is. In this case, an
ALKALOSIS.

Step Two
If the ABG results are abnormal, determine if the abnormality is
due to the kidneys (metabolic) or the lungs (respiratory).
Match the two abnormalities: Kidneys (metabolic)) +
Alkalosis = Metabolic Alkalosis.

Example 2
Jane Doe is a 55 year old admitted to your nursing unit with
sepsis. Here is her arterial blood gas result: pH 7.31, pCO2 39,
HCO3 17
Step One
Identify whether pH, pCO2 and HCO3 are abnormal. For each
component, label it as “normal”, “acid” or “alkaline”
The two matching values determine what the problem is. In this
case, an ACIDOSIS.

Step Two
If the ABG results are abnormal, determine if the abnormality is
due to the kidneys (metabolic) or the lungs (respiratory).
Match the two abnormalities: Kidneys (metabolic) + Acidosis =
Metabolic Acidosis.

Cardiovascular Assessment
and Common Disorders

Physical Assessment of
the Cardiovascular System
Techniques
• Inspection
• Palpation
• Percussion
• Auscultation

Specific Areas of the
Cardiovascular Assessment
• Inspection of the face and lips
• Inspection of the jugular veins
• Inspection of the carotid arteries
• Inspection of the hands and fingers
• Inspection of the chest, abdomen, legs and
skeletal structures

Palpating the Carotid artery
• Keep the patient’s head elevated at 30°
• Place your middle and index fingers on the
right then left carotid arteries, and palpate the
carotid upstroke
• NEVER palpate right and left carotid arteries
simultaneously

Percussion
• More often, it is used as part of clinical
evaluation of the lungs and abdomen.
• Percussion of the heart can be useful in
estimating a patient’s heart size and/or
pericardial effusion.

Auscultation
• Listen in all 5 listening areas of the heart for S1
and S2 using the diaphragm of the stethoscope
• Then listen at the apex with the bell
• The diaphragm is best for detecting high-pitched
sounds like S1, S2 and also S4 and most murmurs
• The bell is best for detecting low-pitched sounds
like S3 and the rumble of mitral stenosis.
• Erb’s point is the auscultation location for heart
sounds and heart murmurs located at the third
intercoastal space and the left lower sternal
boarder

Myocardial Infarction
• Also known as Heart Attack
• Newest term: Acute Coronary Syndrome
• Leading cause of death in many countries
• Reduced blood flow through one of the
coronaries in myocardial ischemia and
necrosis
• Usually affects the LV – “workhorse” of the
heart
• Good collateral circulation limits the size of an
MI

• Death usually results from cardiac damage or
complications
• Mortality is high when treatment is delayed
• Almost half of sudden death from MI occur
before hospitalization, within 1hr of the onset
of symptoms.
• Prognosis improves if vigorous treatment
begins immediately
• Early recognition and aggressive treatment is
vital

Risk factors
Modifiable
• Smoking
• High Cholesterol
• Overweight
Non-modifiable
• Family history
• High blood pressure
• Diabetes

Signs and Symptoms
• Persistent,
crushing/heavy/squee
zing substernal chest
pain that may radiate
to the left arm, jaw,
neck or shoulder
blades caused by
decreased O2 supply
to the myocardial cells

Signs and Symptoms
• Cool extremities, perspiration, anxiety and
restlessness
• BP and HR initially elevated
• Decreased UO
• Fatigue and weakness
• SOB and crackles – reflects Heart Failure
• Bradycardia

Diagnosis
• Serial 12 lead ECG
• Serial cardiac enzymes – serum cardiac
markers
myoglobin, CK-MB, Trop.I, Trop. T
• Echocardiography
• Coronary angiography

TREATMENT
• Thrombolytic therapy
most effective within the first 3hours after onset of symptoms
• Heparin
• Limitation of physical activities
• M = Morphine or Meperidine
• O = Oxygen
• N = Nitrates (do not give for SBP<90, HR<50
• A = Aspirin
• Coronary Angioplasty
• Bypass (CABG)

NURSING CARE
• Establish an IV line
• VS and Cardiac Monitoring
• NPO except sips of water until stable
• Diet: Low salt, low fat
• Complete bed rest without bathroom
privileges
• Oxygen: 2-3lpm via nasal cannula
• Stool softener as prescribed

Cardiac Tamponade
• A rapid, unchecked increase in pressure in the
pericardial sac that compresses the heart
impairs diastolic filling and reduce cardiac
output
• Usually results from blood or fluid
accumulating in the pericardial sac
• Rapid collection of fluid in the pericardial sac
interferes with ventricular filling and
pumping, critically reducing cardiac output.
• Considered a medical emergency – therefore,
must be aggressively treated to preserve life

Cardiac Tamponade
CAUSES
• Idiopathic
• Effusion – from CA, Bacterial infxn, TB, RH
fever
• Hemorrhage – from traumatic causes
• Hemorrhage – from non-traumatic causes e.g
anticoagulant therapy
• Viral or post radiation pericarditis
• Chronic renal failure requiring dialysis
• Connective tissue disorder
• AMI

Cardiac Tamponade
Signs and Symptoms
• Elevated CVP with jugular vein distention
• Muffled heart sounds
• Diaphoresis and cool, clammy skin
• Anxiety, restlessness and syncope
• Cyanosis
• Weak, rapid pulses
• Cough, dyspnea, orthopnea
• Pulsus Parodoxus – classic manifestation of
cardiac tamponade
- A decrease in SBP>15 during
inspiration

Cardiac Tamponade
DIAGNOSIS
• CXR
• ECG – may show a low amplitude QRS
complex and generalized ST segment
elevation is noted in all leads
• PA Catheterization
• Echocardiography

Cardiac Tamponade
NURSING CARE
• Collaborative management
• Report significant changes or trends in
hemodynamic parameters and dysrrhythmias.
• Maintain atleast 1 patient IV access site
• Prepare for emergency pericardiocentesis
and/or emergency surgery as necessary.
• Support client towards independence

Cardiac Tamponade
TREATMENT
• Supplemental o2
• Continuous ECG and hemodynamic monitoring
• Trial volume loading crystalloids – to maintain SBP
• Inotropic drugs
• NSAIDS
• Pericardial window – surgical creation of opening
• Pericardiocentesis – needle aspiration
• Administration of heparin antagonist (Protamine)
-to stop bleeding in heparin-induced tamponade
• Use of Vit.K in warfarin-induced tamponade

Heart Failure
CAUSES:
• Pump failure
• Cardiomyopathy, MI
• Valvular stenosis
• COPD
• HPN
• Pericarditis
• AF

Heart Failure
TREATMENT: LSHF
• ACE inhibitors (-pril) –reduce preload &
afterload
• Digoxin- increase contractility, c.o, reduce vol.
in LV
• Diuretics
• Oxygen
• Beta-adrenergic blockers (-olol)

Heart Failure
TREATMENT: RSHF
• Diuretics – reduce preload
• Nitrates –vasodilation, reduce preload
• Morphine – vasodilation
• Oxygen

Heart Failure
PATIENT TEACHING
• Avoid foods high in Na+ to curb fluid overload
• Replace K+ loss through diuretics
• Weigh patient daily and record
• Stress the importance of taking meds as
prescribed
• Instruct patient to check his own pulse and
report if <60bpm

Computation of Cardiac
Medications

Neurologic Assessment
NIHSS 11 categories
• Level of consciousness
Orientation
Commands
• Best Gaze
• Visual fields
• Facial palsy
• Motors (R&L) – Arms and Legs
• Limb ataxia
• Sensation
• Best language
• Dysarthria
• Extinction and inattention

1A. Level of consciousness (LOC)
• Alert 0
• Arousable by minor stimulation 1
• Not alert, requires repeated 2
stimulation; Obtunded
• Unresponsive 3

1B. LOC questions
• Answers both correctly 0
• Answers one correctly 1
• Both incorrect 2
• Standard questions
• A. What month is it today?
• B. How old are you?

1C. LOC Commands
• Obeys both correctly 0
• Obeys one correctly 1
• Both incorrect 2
• Standard Commands
• A. Can you open and close your eyes?
• B. Can you make a fist?

Gaze testing
2. Best gaze
• Normal 0
• Partial gaze palsy 1
• Force deviation or 2
total gaze paresis

3. Visual field test
• Normal 0
• Partial hemianopia 1
• Complete hemianopia 2
• Bilateral hemianopia 3
(Blind including cortical blindness)

4. Facial palsy
• Normal 0
• Minor paralysis 1
• Partial paralysis 2
• Complete paralysis 3
• Observe for nasolabial fold

5A and 5B Motor (Arm)
• Normal 0
• Drifts before 10secs 1
• Falls before 10 seconds 2
• No effort against gravity 3
• No movement 4

6A and 6B Motor (Leg)
• Normal 0
• Drifts before 10secs 1
• Falls before 10 seconds 2
• No effort against gravity 3
• No movement 4

7. Limb ataxia
• No ataxia 0
• Present in one limb 1
• Present in two limbs 2
• Using:
• Arms: finger to nose test
• Legs: heel to shin test

8. Sensory
• Normal 0
• Mild to moderate sensory loss 1
• Severe to total sensory loss 2
• Using: pinprick method

9. Best Language (picture tools for aphasia)

9. Best Language
• Normal 0
• Mild to moderate aphasia 1
• Severe aphasia 2
• Mute, global aphasia 3
• Ask the patient to name items on the picture
tools.

10. Dysarthria (reading texts)
• Normal 0
• Mild to moderate dysarthria 1
• Severe dysarthria 2

11. Extinction and Inattention
• Normal 1
• Visual, tactile, auditory or 2
personal inattention
• Profound hemi-attention or 3
extinction to more than one modality

National Institute of Health Stroke Scale (NIHSS)
• No symptom 0
• Minor 1-4
• Moderate 5-15
• Moderately-severe 16-20
• Severe 21-42

Stroke Monitoring Tool

Stroke- Treatment Pathway
1. Rapid patient recognition and reaction to stroke
warning signs
2. Rapid emergency medical services (EMS)
dispatch
3. Rapid EMS system transport and hospital pre-
notification
4. Delivery direct to imaging
5. Rapid in-hospital diagnosis and treatment
*Effective EMS system can minimize delays in pre-
hospital dispatch, assessment and transport & increase
the number of patients reaching hospital and receiving
thrombolytic therapy w/in the approved time window.

Intravenous Thrombolysis (rTpa)
- Is a treatment to dissolve dangerous clots to
improve blood flow and prevent damage to
tissue and organs
- May involve the injection of clot-busting drugs
through an IV line or through a long catheter
that delivers drug directly to the site of blockage.
- It also involves the use of long catheter with
mechanical device attached to the tip that either
removes the clot or physically breaks it up.
- It is given to patients with ischemic stroke,
arrived at the ER within the Golden period from
the onset of stroke (3 to 4.5 hours).

Computation for rTpa
*obtain weight of patient in kilograms
Dose = 0.9mg/kg (not to exceed 90mg)
*initial 10% given as iv bolus for 1 minute
*remaining 90% as infusion drip over 60minutes

Basic ECG Tracing
Normal Sinus Rhythm

CRITICAL CARE NURSING MODULE FOR NURSES.pptx

CRITICAL CARE NURSING MODULE FOR NURSES.pptx

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