The document discusses several special populations that are commonly encountered in critical care, including pediatric patients, pregnant women, older adults, and post-anesthesia patients. It outlines the anatomical, physiological, and medical differences that necessitate specialized care approaches for each of these groups. Potential complications are also reviewed, emphasizing the importance of understanding how to assess and manage risks in these vulnerable patient populations.

1. SPECIAL POPULATION
By
Yasmeen Rahim

2. OBJECTIVES
By the end of this
presentation, learners will be able to:
 Identify special population for critical
care.
Pediatric patient
Pregnant woman
Old patient
Post anesthesia patient

3. PEDIATRIC PATIENT

4. ANATOMICAL &
PHYSIOLOGICAL DIFFERENCE:
 VITAL SIGNS:
• Normals change with age
• Children have high HR and RR to meet a
need of higher CO
• Blood pressure is the last vital sign to change
in a child with shock.
• Children can compensate up to 25% of blood
loss.
• Bradycardia is not well tolerated in young
children and can be precipitated by hypoxia.

5. CONT
• It can be due to vagal stimulation for e.g.
while doing suctioning or while inserting
NG tube.
• Bradycardia is not acceptable because high
cardiac output is needed to fulfill increase
metabolic demands of the body.
• Tachycardia can be a nonspecific response
to many conditions like
fever, anxiety, shock, hypoxemia etc.
• Tachypnea might indicate respiratory
distress for eg in fever and in seizures etc.
• Bradypnea may indicate respiratory arrest.

7. CONT.
 NEUROLOGICAL SYSTEM:
• Needs to be age appropriate
• Head circumference measurement is
important until 2 years of age
• Reflexes
 Grasp reflex, babinski reflex, rooting etc.
• Fontanels
 Posterior fontanel close by 3 months and
anterior closes by 9 – 18 months.
 Fontanels are also used to assess hydration
status and ICP.

8. CONT.
• High risk for ineffective thermoregulation
• Mental status
LOC is assessed whether child is arousable
and oriented
Interaction with the environment
Knows Mom and Dad
Awake, looking around
Assessment should be same like adults but
technique would be different.

9. CONT.
 CARDIOVASCULAR SYSTEM:
• Cardiac assessment
• Skin color
 Peripheral cyanosis normal for newborn only
 Central cyanosis always abnormal
 Mottling – take into consideration room
temperature
• Capillary refill time is less then 2
seconds
• Estimated blood volume varies with age
and body weight.

11. CONT.
 RESPIRATORY SYSTEM:
• Infants under 6 months are obligatory nose
breathers
• Smaller airway in diameter and length, easily
occlude
• Nurse must avoid over extending or over
flexing of neck because airway can easily
occlude.
• Small roll should be kept behind the
shoulders to prevent obstruction.

12. CONT.
• Nurse should also look for nasal
obstruction which can be caused by
obstruction, secretions, edema, inflammati
on or poor NG taping.
• Watch for retractions
 Abdominal breathing as their accessory
muscles are not yet developed.
• Listen breath sounds, look for chest rise
and fall.
 Stridor
 Wheezing for sounds
 If unequal then suspect Pnuemothorax or
atelactasis or ETT obstruction or dislodgement.

13. CONT.
 GASTROINTESTINAL SYSTEM:
• Protuberant abdomen but different causes of
abdominal distention.
• Abdominal girth is measured every shift
• Stomach capacity varies with the age of the
child therefore feeding should be of an
appropriate amount.
• Newborn stomach capacity is 90 ml, 1 month
old is 150 ml, 12 month old is 360 ml
• If child is receiving chest physiotherapy then
NG aspiration should be check to avoid
aspiration.

14. CONT.
 RENAL SYSTEM:
• Normal urine output
 Infants: 2mL/kg/hour
• Decreased ability to concentrate urine
 Children: 1mL/kg/hour
 Adolescents: 0.5ml/kg/hour
• Increased risk of dehydration
 Dry mucous membranes
 Poor skin turgor
 Sunken fontanels
 Decrease urine output
 Increase urine concentration

15. CONT.
 ENDOCRINE SYSTEM:
• Increase glucose demand because
of large brain to body size ratio.
• Smaller glycogen stores.
• Children are more prone to develop
hypoglycemia.
• Blood glucose levels should be
closely monitored.

16. CONT.
 IMMUNE SYSTEM:
• Children and infants are more prone to
get infections.
• Skin is thinner so provide less barrier to
pathogens.
• Children may not demonstrate fever and
leukocytosis in response to infection
(fewer stored neutrophils)
• Signs should observe like altered
feeding behavior, hypothermia, altered
glucose metabolism etc.

17. CONT.
 INTEGUMENTARY SYSTEM:
• Skin, hair, nails and glands of children
depends upon the age of children.
• They have less adipose tissues therefore
they are more prone to get
hypothermia.
• Sweat gland not functional until 1
month of age
• Bruises should be noticed deeply for
location and color changes as it can be
associated with abuse.

18. OTHER CHALLANGES
 Ventilatory issues
• Respiratory distress, bag mask
ventilation and ETT intubation
 Medication administration
• According to body weight
 Pain management
• Pain assessment scales
 Interaction with children and family

21. PREGNANT WOMAN

22. PHYSIOLOGICAL CHANGES
 CARDIOVASCULAR CHANGES:
• Maternal blood volume increases 40%
to 50% above baseline.
• Increase in cardiac output of 30% to
50%.
• Blood pressure during pregnancy is
affected by maternal position.
• Side lying position is usually
recommended.

23. CONT.
 RESPIRATORY CHANGES:
• Respiratory changes occur to
accommodate the enlarged uterus and
the increased oxygen demands of the
mother and fetus.
• Oxygen consumption increases by 15%
to 20% during pregnancy
• Respiratory rate remains
unchanged, although some women
experience tachypnea or shortness of
breath at some time during their
pregnancy

24. CONT.
 RENAL SYSTEM:
• Renal blood flow increases by 30%
• Glomerular filtration rate (GFR)
increases by 50% to accommodate the
increase in metabolic and circulatory
requirements of pregnancy.
• These increases allow elevations in the
clearance of many substances, such as
creatinine and urea, and are reflected in
lower serum levels

25. CONT.
 GASTROINTESTINAL & METABOLIC
CHANGES:
• The pregnant woman is prone to
passive regurgitation and aspiration
• Smooth muscle relaxation contributes to
nausea, heartburn, and constipation.
• Hepatic and maternal fasting blood
glucose levels decrease owing to the
constant transfer of glucose to the fetus

26. CONT.
 HEMATOLOGICAL CHANGES:
• Hematocrit values decreases because of
hemodilution effect of increase plasma.
• White blood cell count is increased from
the normal range of 5,000 to
10,000/mm3 to 6,000 to 16,000/mm3.
• Bleeding, clotting time and platelet counts
remain same throughout the pregnancy.

27. CONT.
 FETAL AND PLACENTAL
DEVELOPMENTAL CONSIDERATION:
• Treatment decisions should be carefully
taken.
• Teratogens and teratogenic effect.
• Placental functions depends on maternal
blood flow.
• Hypertension, cocaine, smoking, alcohol
ism can cause vasoconstriction

28. CRITICAL CARE COMPLICATION
 Severe pre - eclampsia
(hypertension, edema and proteinuria)
*hypertension greater than 140 / 90 and severe
greater than 160 / 110
 HELLP syndrome– Hemolysis, elevated
liver enzymes and low platelets
 DIC – Disseminated intravascular
coagulation
 Amniotic fluid embolus
 ARDS – Acute respiratory distress
syndrome
 Trauma

30. CRITICALLY ILL OLDER
 The leading causes of death among
older patients are heart
disease, malignant
neoplasms, cerebrovascular
accidents, influenza, and chronic
obstructive pulmonary disease.
 When older adults have acute
exacerbations of their diseases, they
often require hospitalization in an
intensive care unit (ICU)

31. CONT.
 Critical care nurses need to
understand the many physiological
changes that occur normally with
aging.
 These age-related changes put the
critically ill older adult at increased
risk for complications.

32. CONT.
 BIOLOGICAL ISSUES:
• Reduced resistance to stress
• Poor tolerance of extremes of heat and cold
because of hypothalamic and skin changes
• Greater fluctuation in blood Ph
• The amount of connective and collagen tissue
is increased.
• Cellular elements in the nervous
system, muscles, and other vital organs
disappear.
• The number of normally functioning cells is
reduced.
• The amount of fat is increased.

33. CONT.
• Oxygen use is decreased.
• During rest, the amount of blood pumped is
decreased.
• Less air is expired by the lungs.
• Excretion of hormones is decreased.
• Sensory and perceptual activity is decreased.
• Absorption of lipids, proteins, and
carbohydrates is decreased.
• The arterial lumen thickens.
• Decrease in quality of sleep.

34. CONT.
 PSYCHOSOCIAL ISSUES:
• Deciding where and how to live for his
or her remaining years
• Providing sufficient income
• Maintaining a maximum level of health
• Recognizing and feeling that he or she is
needed
• Maintaining an adequate and satisfying
home environment relative to health
and economic status

35. CONT.
 PHYSICAL CHALLENGES:
• Auditory changes
• Visual changes
• Other sensory changes (decrease taste buds, loss
of tactile sensation etc)
• Sleep changes
• Skin changes
• Cardiovascular changes
• Respiratory changes
• Gastrointestinal changes
• Musculoskeletal changes
• Renal changes
• Endocrine changes
• Immunological changes

36. POST ANESTHESIA PATIENT

37. POST ANESTHESIA PATIENT
 The time immediately after surgery
is most crucial period in the patient’s
recovery from anesthesia.
 The nurse should know what
happens in operating room as it can
affect the patient's immediate
postoperative care.

38. Cont.
 Sedation: An induced state of
quiet, calm, or sleep by means of a
medication.
 Minimal sedation: A state in which the
patient responds normally to verbal
stimuli.
 Moderate sedation: A drug-induced
depression of consciousness during which
the patient responds purposefully to
verbal commands either alone or in
conjunction with tactile stimulation. The
patient's protective reflexes remain intact.

39. Cont.
 Deep sedation:
• A state during which the patient cannot
be easily aroused.
• Patient responds purposefully after
repeated or painful stimulation.
• Spontaneous ventilation and the ability
to maintain a patent airway may be
impaired.

40. Cont.
 General anesthesia:
• A state during which a patient cannot be
aroused, even by painful stimulation.
• The ability to independently maintain
ventilatory function is often impaired.
• Cardiovascular function may be
impaired.

41. Cont.
 The initial parameters assessed by
nurse are:
• Vital signs ( every 15 min)
• Pulse oximetry
• Level of consciousness
• Cardiac rhythm
• Hemodynamic monitoring
• Urine output
• Estimated blood loss

42. POTENTIAL PROBLEMS IN PAP
 AIRWAY! AIRWAY! AIRWAY! AIRWAY!
 Hypoventilation
 Hypoxemia
 Hypotension
 Hypertension
 Cardiac dysrhythmias
 Hypothermia
 Hyperthermia
 Nausea and vomiting
 Pain

43. GROUP ACTIVITY