Chapter 66: Nursing Management Critical CareCritical Care Nursing Critical Care/Intensive Care Units PICU any type of pediatric intensive care patient except cardiac NICU infant that has to have never left the hospital Critical Care Nurse Performs frequent assessments to monitor trends in patients physiologic parameters (BP, ECG, etc.) Provides psychologic support to patient and caregiver(s) Important to be skilled in palliative and end-of-life care Certifications critical care nurses can get Critical Care Certification (CCRN) Progressive Care Certification (PCCN) Cardiac Medicine (CMC) Cardiac Surgery (CSC) Nurses should be aware of the scope of practice provided by their state's Nurse Practice Act In general, nurses can provide Patient and caregiver teaching about an illness or disease The general course of illness What usual treatment entails Diagnosis and prognosis are outside the scope of practice for a registered nurse Critical Care Patient Common Problems of Critical Care Patients Usually immobile and at high risk for thromboembolism and skin problems Use of multiple invasive devices predisposes patient to hospital-acquired infections Sepsis and multiple organ dysfunction (MODS) may follow Nutrition Must collaborate with physician and dietician to determine how to meet nutritional needs Primary goal is to prevent or correct nutritional deficiencies Usually accomplished with Enteral (calories via GI tract) and Parenteral (calories via IV) nutrition Enteral nutrition is usually encouraged Preserves the structure and function of the gut mucosa Prevents the movement of gut bacteria across the intestinal wall and into the bloodstream In addition, early enteral nutrition is associated with fewer complications and shorter hospital stays, and is less expensive than parenteral nutrition Parenteral nutrition is used when Enteral route is unsuccessful or contraindicated Paralytic ileus, diffuse peritonitis, intestinal obstruction, pancreatitis, GI ischemia, intractable vomiting, and severe diarrhea Anxiety Encourage patients and caregivers to express concerns, ask questions, and state their needs Include patient & caregiver in all conversations and explain purpose of equipment & procedures Structure patient's surrounding environment in a way that decreases anxiety For example, encourage caregivers to bring in photographs and personal items Judicious use of antianxiety drugs (e.g., lorazepam [Ativan]) and complementary therapies (e.g., guided imagery, massage) may reduce stress response that can be triggered by anxiety Pain Control of pain is paramount as many as 70% in ICU have moderate to severe uncontrolled pain ICU patients at high risk for pain include patients who Have medical conditions that include ischemic, infectious, or inflammatory processes Are immobilized Have invasive monitoring devices, including endotracheal tubes Require invasive or noninvasive procedures If giving Propofol for sedation, a daily sedation vacation (interruption of sedation) should be conducted allows patient to wake so a neurological assessment can be done Patients who are intubated can feel pain (could be grimacing or show change in vitals) If doing a dressing change, should give them prophylactic pain meds Impaired communication Some patients may not be able to speak b/c of the use of sedative and paralyzing drugs or an endotracheal tube Always explain what will happen or is happening to the patient when doing any procedure Explore using picture boards, notepads, magic slates, or computer keyboards if they cant talk Look directly at patient when speaking to them and use gestures when appropriate Comfort touch is important to some patients Encourage caregivers to touch and talk with the patient even if patient is unresponsive or comatose Sensory-Perceptual Problems Estimated that the prevalence of delirium in ICU patients is as high as 80% Factors Predisposing Patient to Delirium Demographic factors advanced age, preexisting cognitive impairment, vision/hearing impairments, history of drug or alcohol abuse Environmental factors sleep deprivation, anxiety, sensory overload, immobilization Physical conditions hemodynamic instability, hypoxemia, hypercarbia, electrolyte disturbances, severe infections Certain drugs sedatives, Lasix, antimicrobials Must address physiologic factors (e.g. correct O2 levels, perfusion, and electrolyte problems) Use of clocks and calendars can help orient patient Presence of caregiver may help orient patient and reduce agitation Neuroleptic drugs (Haldol) can be used if patient demonstrates hyperactivity, insomnia, delusions Limit noise and explain noises that cannot be prevented Have conversations out of patient area unless involving patient in conversation Silent unnecessary alarms while doing procedures then reactivate them when done Sleep Problems Nearly all patients in ICU experience sleep disturbances significant stressor in ICU Contributes to delirium and possibly affects recovery Structure environment to promote patients sleep-wake cycle Cluster activities Schedule rest periods Dim lights at nighttime Open curtains during the daytime Obtain physiologic measurements w/o disturbing patient Limit noise Provide comfort measures (e.g. back rubs) Many patients on sleep aids to induce/maintain sleep benzos (Restoril) & benzo-like (Ambien) Issues Related to Caregivers To be effective in caring for their loved one, caregivers need your guidance and support Caregivers experience anxiety regarding patients condition, prognosis, pain and other discomforts, and finances If anxious about finances, consulting with case manager or social worker is helpful Nurses must provide family-centered care need skills in crisis intervention Interventions active listening, reduction of anxiety, support of those who become upset or angry, acknowledgment of caregivers feelings and acceptance of their decisions, meeting informational, reassurance, and convenience needs Note: patients often exhibit early and subtle signs of deterioration (e.g. mild confusion, tachycardia) 6-8 hours before cardiac and/or respiratory arrest

Drugs Related to Critical Care Dopamine Increases contractility of the heart CO is increased Renal dose will open up the kidney function and helps increase urine output At higher levels, blood pressure is increased and renal perfusion is decreased Dobutamine Helps the heart pump efficiently Use in cardiogenic shock Levophed Vasoconstriction, which helps increase blood pressure Long-term use can cause necrosis of the extremities fingers, toes, etc. Nitroglycerin Vasodilation, which relieves chest pain Can give the patient a severe headache usually will give them Tylenol as well Propofol Sedation Also helps for nausea leaves the body very quickly so it does not help the nausea for long Can drop BP quickly Two Types Regular Nut based watch for nut allergies to avoid anaphylaxis Prescedex Sedation Epinephrine Low BP, allergic reaction Norepenephrine/Levophed Shunt the blood to vital organ extremities are effected the most Amiodorone Antidysmic

Hemodynamic Monitoring Measurement of pressure, flow, and oxygenation within the cardiovascular system Invasive monitoring internally placed devices Noninvasive monitoring external devices Values Commonly Measured in the ICU Systemic and pulmonary arterial pressures Central venous pressure (CVP) Pulmonary artery wedge pressure (PAWP) (also known as pulmonary artery occlusive pressure [PAOP]) CO/CI SV/SV index [SVI] O2 saturation of the hemoglobin of arterial blood (SaO2) Mixed venous oxygen saturation (SvO2) These measurements allow you to calculate Resistance of the systemic and pulmonary arterial vasculature O2 content, delivery, and consumption Hemodynamic Terminology Cardiac Output volume of blood in liters pumped by the heart in 1 minute Cardiac Index measurement of CO adjusted for body surface area (BSA) More precise measurement of the efficiency of the pumping action of the heart Preload volume in ventricle at the end of diastole Afterload forces opposing ventricular ejection Systemic arterial pressure, resistance by aortic valve, and mass and density of the blood to be moved WANT TO LOOK AT SVR IN REGARDS TO AFTERLOAD (systemic vascular resistance) Systemic Vascular Resistance resistance of the systemic vascular bed Pulmonary Vascular Resistance resistance of the pulmonary vascular bed Contractility strength of the contraction If preload, heart rate, and afterload remain constant yet CO changes, contractility is changed Contractility is reduced in the failing heart

Principles of Invasive Pressure Monitoring Invasive lines used in the ICU to measure systemic and pulmonary BPs Pressure monitoring equipment is referenced and zero balanced to the environment Referencing positioning transducer so the zero reference point is at the level of the atria of the heart Stopcock nearest transducer usually the zero reference for the transducer To place this level with atria, need to find phlebostatic axis Transducers placed higher than the phlebostatic axis will produce falsely low readings Transducers placed lower than the phlebostatic axis will produce falsely high readings Zeroing confirms that when pressure within the system is zero, the monitor reads zero Open reference stopcock to room air (off the patient) and watch for a reading of zero This allows use of atmospheric pressure as a reference for zero When to Zero? During the initial setup Immediately after insertion of arterial line when transducer has been disconnected from pressure cable or pressure cable has been disconnected from monitor When the accuracy of the measurements is questioned Types of Invasive Pressure Monitoring Arterial Blood Pressure 20 gauge in the radial or femoral artery sutured in place Measurement of Blood Pressure with Invasive Lines Radial, brachial, or femoral Want to watch for infection red, swollen Should have good wave form and be zeroed (check zero to the transducer at the 4th intercostal space) Cuff pressure should be within 10 of arterial pressure Complications Hemorrhage use Luer-Lok connections, check arterial waveforms, and activate alarms If pressure in line falls (when line disconnects) an alarm will sound Infection inspect insertion site for inflammation/infection Change pressure tubing, flush bag, and transducer q96h When infection is suspected, remove catheter and replace equipment Thrombus formation To limit thrombus formation and maintain line patency, check continuous flush system q1-4h to make sure the pressure bag is inflated to 300 mm Hg, the flush bag contains fluid, and the system is delivering 3-6 mL/hour Should not be using heparin routinely for flush solution risk for thrombocytopenia Neurovascular impairment Loss of limb

Pulmonary Artery Flow-Directed Catheter Pulmonary Artery Catheter Insertion Note patients electrolyte, acid-base, oxygenation, and coagulation status Imbalances such as hypokalemia, hypomagnesemia, hypoxemia, or acidosis can make heart more irritable & increase risk of ventricular dysrhythmia during catheter insertion To maintain position, catheter is secured at point of entry on skin and length marked

Pulmonary Artery Pressure Measurements PAD (pulmonary artery diastolic pressure) & PAWP (pulmonary artery wedge pressure) Both are sensitive indicators of cardiac function and fluid volume status Both increase in heart failure and fluid volume overload Both with volume depletion PAWP is pressure generated by left ventricle (left ventricle function) Basing fluid therapy on PA pressure can restore fluid balance w/o overcorrection or undercorrection of the problem (can avoid pulmonary edema) Complications with Pulmonary Artery Catheters Infection and Sepsis Must have careful surgical asepsis for insertion and maintenance of catheter & tubing Monitor patient for local and systemic changes redness, exudate at insertion site, fever, increased WBC count Must remove catheter if there are any signs of infection To reduce risk of infection change flush bag, pressure tubing, & stopcock q96h and remove hemodynamic monitoring once it is no longer needed Air Embolus Always check balloon integrity before insertion discard defective catheters After insertion, balloon rupture or injection of air into any lumen can cause air embolus To reduce risk of air embolus first aspirate blood to check for absence or presence of blood and only inject prescribed volume of air into balloon before obtaining PAWP If blood is aspirated from balloon port or balloon air does not all come back into the syringe, label port do not use and contact physician Always use Luer-Loks on all pressure lines and activate low pressure alarms Pulmonary Infarction or PA Rupture Causes Balloon may rupture, releasing air and fragments that could embolize Prolonged balloon inflation may obstruct blood flow Catheter may advance into a wedge position, obstructing blood flow Thrombus could form and embolize To reduce risk of air embolus/pulmonary infarction never inflate balloon beyond capacity (1-1.5 mL of air), monitor PA pressure waveforms continuously for evidence of catheter occlusion, dislocation, or spontaneous wedging Pressure tracing will be blunted with occlusion and will appear wedged if PA catheter advances and becomes wedged Physician must reposition catheter immediately ALWAYS CLOSE LINE WITH CLAMP OR STOPCOCK WHEN LINE IS DISCONNECTED NEVER LEAVE BALLOON INFLATED FOR MORE THAN 4 BREATHS (8-15 SECONDS) EXCEPT DURING INSERTION To reduce risk of thrombus/embolus formation PA catheter needs to be continuously flushed with a slow infusion of normal saline Ventricular Dysrhythmias Can occur during PA catheter insertion or removal or if tip moves from PA to R ventricle and irritates ventricular wall (PA catheter would not be able to be wedged) Needs to be repositioned by physician and chest x-ray done to confirm location Central Venous or Right Atrial Pressure Measurement (CVP) Measurement of right ventricular preload Measured with PA catheter using the proximal lumen located in the right atrium or with a central venous catheter placed in the internal jugular or subclavian vein Also reflects fluid volume problems, but PA diastolic pressure & PAWP are better indicators of it Increase in CVP reflects heart failure or volume overload WANT TO CVP TO CARDIAC OUPUT!!! Decrease in CVP reflects volume depletion CVP Waveform Interpretation a wave represents atrial contraction x descent represents atrial relaxation c wave represents the bulging of the closed tricuspid valve into the right atrium during ventricular systole v wave represents atrial filling y descent represents opening of the tricuspid valve and filling of the ventricle

Invasive Cardiac Output Measurement Techniques Normal resting cardiac output is 4-8L per minute CO & CI are in shock states (e.g. cardiogenic, hypovolemic) and heart failure CO with exercise and at rest with fever or early sepsis TDCO (intermittent bolus thermodilution CO) CO is calculated from temperature change in pulmonary artery when a fixed volume and known temperature of a solution is injected into proximal port in right atrium CO measured by computer from area under the temp curve Want curve to be smooth Larger area under curve = lower CO Smaller area under curve = higher CO Repeat 3x with each measurement 1-2 minutes apart to determine CO Must have three normal curves to be valid throw out any abnormal curves CCO (continuous cardiac output method) CO measured with a PA catheter (placed in the right atrium) that has a heat-exchange CO catheter attached to detect changes in temp when blood passes through R ventricle Every 30-60 seconds, a bedside computer displays average CO for the past 3-6 minutes Eliminates need for fluid boluses, decreases contamination, permits ongoing evaluation MORE RELIABLE THAN TDCO METHOD Minimally Invasive Cardiac Output Monitoring Techniques Use of a specialized sensor that attaches to a standard arterial pressure line and a monitor Measures CCO/CCI, SV/SVI, and stroke volume variation q20secs More research needed to find if this approach can replace hemodynamic monitoring with PA catheter Venous Oxygen Saturation Both CVP (central venous pressure) and PA (pulmonary artery) catheters can include sensors to measure O2 saturation of hemoglobin in venous blood O2 saturation of blood from PA catheter = mixed venous oxygen saturation (SvO) O2 saturation of blood from CVP catheter = central venous oxygen saturation (ScvO) Both are adequate for the measurement of adequate tissue oxygenation Normal SvO/ScvO at rest is 60-80% SvO/ScvO arterial oxygenation, low CO, low hemoglobin, consumption or extraction of O If below 60%, observe for changes in arterial oxygenation Monitor pulse oximetry or ABGs Indirectly assess CO and tissue perfusion changes in mental status, strength or quality of peripheral pulses, capillary refill, urine output, skin color & temp If arterial oxygenation, CO, and hemoglobin are unchanged, the in SvO/ScvO is from O consumption or extraction could be metabolic rate, pain, movement, or fever SvO/ScvO Could be from an improvement (e.g. O saturation, improved perfusion, metabolic rate) or from a problem (e.g. sepsis) In sepsis there is a ability of tissues to use O at the cellular level

Noninvasive Hemodynamic Monitoring Impedance Cardiography (ICG) Method of obtaining CO and assessing thoracic fluid status continuous or intermittent Uses four external electrodes that deliver a high frequency, low amplitude current to measure the change in impedance in the ascending aorta and left ventricle over time Impedance the resistance to the flow of electric current Cannot use in patients with generalized edema or third spacing excess volume interferes with accuracy Noninvasive Arterial Oxygenation Monitoring Pulse Oximetry Monitoring SpO may reduce frequency of ABG sampling SpO is normally 95%-100% Can put pulse ox probe on forehead, earlobe, etc. if cannot get good reading on fingers Normally used to evaluate effectiveness of oxygen therapy and how patient tolerates position changes or decreases in fraction of inspired air (FIO) Nursing Management of a Patient on Hemodynamic Monitoring Obtain Baseline Data General appearance Does the patient appear tired, weak, exhausted? Level of consciousness Cardiac reserve may be insufficient to sustain even minimum activity Changes in mental clarity may reflect problems with cerebral perfusion or oxygenation Skin color/temperature Pallor, cool skin, and diminished pulses may indicate decreased CO If patient is bleeding and developing shock, BP might initially be stable, yet patient may become increasingly pale and cool from peripheral vasoconstriction Conversely, patient with septic shock may remain warm/pink yet develops tachycardia and BP instability Vital signs Peripheral pulses Capillary Refill Urine output Monitoring urine output reflects the adequacy of perfusion to the kidneys Patient with diminished perfusion to GI tract may have hypoactive or absent bowel sounds Correlate baseline data with data obtained from biotechnology e.g., ECG; arterial, CVP, PA, and PAWP pressures; SvO2/ScvO2 Single hemodynamic values are rarely significant Monitor the whole clinical picture

Circulatory Assist Devices (CADs) Used to decrease cardiac work & improve organ perfusion in patients with heart failure when drugs are no longer adequate All CADs decrease ventricular workload, increase myocardial perfusion, and augment circulation Provide Interim Support in Three Types of Situations Left, right, or both ventricles require support while recovering from acute injury (e.g., postcardiotomy) Patient must be stabilized before surgical repair of the heart (e.g., a ruptured septum) Heart has failed, and the patient is awaiting cardiac transplantation Intraaortic Balloon Pump (IABP) most commonly used CAD Provides temporary circulatory assistance (improving coronary blood flow) to compromised heart by Reducing afterload (reducing systolic pressure) Enhancing the aortic diastolic pressure

Balloon inserted percutaneously or surgically into the femoral artery, advanced toward the heart, and positioned in the descending thoracic aorta just below the left subclavian artery and above the renal arteries During systole balloon is deflated (on R wave), which facilitates ejection of the blood into the periphery In early diastole, balloon begins to inflate (on T wave) In late diastole, balloon is totally inflated Increases aortic pressure and increases coronary perfusion pressure with the end result of increased coronary and cerebral blood flow X-ray is used to verify location after placement IABP therapy is called Counterpulsation balloon inflation is opposite to ventricular contraction 1:1 ratio in acute phase of treatment one IABP cycle of inflation and deflation for every heartbeat

Complications with IABP Therapy Signs of a leak include Less effective augmentation Repeated alarms for gas loss Blood backing up into the catheter Patient is relatively immobile, limited to side-lying or supine positions with HOB