Project Elc 2- Tools in Assessing Critically Ill Patient

8/11/2019 Project Elc 2- Tools in Assessing Critically Ill Patient

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A. General information

1. Critical care nursing deals with human responses to life-threatening problems and includesthe critically ill patient , the critical care nurse , and the critical care environment.2. It is the field of nursing with a focus on the care of the critically ill or unstable patients.

3. Care is provided to patients of all ages with alterations in physical or emotional health.4. The critical care nurse coordinates interventions aimed at resolving life-threatening problems.

5. Critical care nurses can be found working in a wide variety of environments and specialties, such asemergency departments and the intensive care units.

B. Critically Ill Patient

1. Critically ill patients are defined as those patients who are at high risk for actual or potential life-threatening health problems.

2. The critically ill patient is at high risk for developing life-threatening problems and requires constant,intensive, multidisciplinary assessment and intervention to restore stability, prevent complications, andachieve and maintain optimal responses

3. The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable andcomplex, thereby requiring intense and vigilant nursing care .

3. A management and administrative structure is required to ensure effective care through all phases ofthe patients hospita l stay, from emergency department to discharge

4. Legal, regulatory, social, economic, and political trends must be monitored to promote the earlyrecognition of problems and a timely response

5. Specialized electronic technology and techniques are used to monitor patient status continuously; thesemay create safety hazards for patients, such as possible exposure to electric shock

D. Roles of the critical care nurse 1. Care provider: provides comprehensive and at times highly technical direct care to the patient and

family in response to life-threatening health problems

2. Educator: provides patient and family with education based on their learning needs and the severity ofthe situation and allows the patient to assume more responsibility for meeting health care needs as healthcondition stabilizes or improves

3. Manager: coordinates the care provided by various health care workers to achieve the specific goal ofproviding optimal nursing care to critically ill patients4. Advocate: protects the patients rights

E. Functions of the critical care nurse


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1. Assesses and implements treatment for patient responses to life-threatening health problems

2. Provides direct measures to resuscitate, if necessary3. Uses independent, dependent, and interdependent interventions to restore stability, preventcomplications, and achieve and maintain optimal patient responses

4. Provides health education to the patient and family5. Supervises patient care and ancillary personnel

6. Supports pati ent adaptation, restores health, and preserves the patients rights, including the right torefuse treatment

F. Legal issues affecting the provision of critical care nursing

1. Negligence2. MALPRACTICE3. INFORMED CONSENT

4. Implied consent5. Advanced directives, including DURABLE POWER OF ATTORNEY and living wills

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ASSESSMENT Assessment is the first step in caring for a patient.

Careful assessment is fundamental in order to recognise when a patient is becoming compromised,

Structured Assessment A AIRWAY (with C spine protection in trauma) B breathing C circulation D disability (central nervous system function) E exposure (with temp. control)

Assessment

What nurses know What nurses see What nurses find a quick physical assessment.

PRIMARY SURVEY eyeball the patient do they look sick? Airway assessment + C-spine If possible trauma protect the C-spine *Can the patient talk normally? (If so, the airway is patent) Stridor/gurgling/snoring (partial airway obstruction) Chest wall movement Feel for breath Look in mouth *Oxygen if patient sick

Airway problems: If evidence of actual or potential airway obstruction get anaesthetics help early Dont wait for O2 saturations to drop by that stage your patient may be in big trouble Remember airway adjuncts if inability to maintain an airway due to decreased conscious level Consider suctioning (call chest physio) if evidence of retained secretions i.e. gurgling noises

Mini assessment

Airway Assessment Determine patency of the airway.

Look. Listen. Feel.Count the Resp. Rate.

AIRWAY OBSTRUCTION Inspiratory Stridor : a rasping sound heard during inspiration as a result of obstruction above or involving the larnyx

Wheeze : is usually heard on expiration as a result of the lower airways collapsingAIRWAY OBSTRUCTION

Gurgling occurs when secretions or liquid is present in the upper airways. Snoring occurs during partial occlusion of the oropharynx due to relaxation of the oropharyngeal muscles and tongue High pitched crowing sounds occur during laryngeal spasm


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BREATHING LOOK

LISTEN

FEELBreathing assessment

look/feel/listen *Obvious distress?

Use of accessory muscles? Cyanosis? *Respiratory rate (This is the single most useful marker of critical illness) Tracheal tug/deviation Chest wall movement + expansion Percussion *Air entry/breath sounds *Added sounds Vocal resonance *Oxygen Saturations (aim for >93%, but if 80mmHg for radial pulse) JVP *BP Heart sounds ?DVT Peripheral oedema ankles/legs/arms/flanks Peripheral pulses *IV access

Circulatory problems:

Shock is a failure to adequately perfuse organs, not just hypotension. Hypotension means advanced shock. Think of the cardiovascular system as plumbing. Things that can go wrong: Not enough fluid (Hypovolaemia e.g. bleeding, vomiting) Pump failure (Cardiogenic shock MI, fluid overload, arrhythmia, valve disease, cardiomyopathy, myocardial depression due to drugs or

acidosis) Blocked pipes (Obstruction to flow PE, cardiac tamponade, high intrathoracic pressures) Leaky or poorly functioning pipes (Vasodilatation septic shock, anaphylaxis)

Finally, neurogenic shock - rare, due to loss of sympathetic input in C/T- spine injuries, causing vasodilatation and bradycardia. In most cases, fluid resuscitation is the first-line treatment for shock, but not always.


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In cardiogenic shock, fluids will tend to make a bad situation worse, and the management is to treat any immediate cause eg arrhythmia or MI,and/or use inotropes.

Unless there is obvious pulmonary oedema, a fluid challenge is worthwhile (250-500mls of colloid e.g. Voluven or Gelofusin over15-30mins, andassess response HR, BP, urine output and CVP if available). Never use hypotonic fluids e.g. 5% dextrose for resuscitation purposes. If bleeding+ hypotensive, use blood, ideally cross-matched.

Disability Neurological assessment

Disability URINE OUTPUT. HALF A ML.X KG. X 24HRS.

OLIGURIA. Production of between 100 400mls x 24hrs.

ANURIA. Below 100mls in 24hrsABSOLUTE ANURIA NO URINE

Disability assessment

Quick neurological screen time to do a full assessment later: AVPU score Alert/Responsive to Voice/Responsive to Pain/Unresponsive Pupils equal & reactive? *GCS (E,M,V) esp. posturing *Check capillary blood glucose

Disability problems

New focal neurology? Is it haemorrhage? this is the most treatable cause. Generalised deterioration in conscious level- 1 CNS cause, or a response to other pathology? Confusion/agitation can be a manifestation of hypoxia/shock/hypoglycaemia/lots of other things for which sedation is not the treatment.

Check capillary blood glucose

EXPOSURE TEMP.

Also a top to toe assessment allow us to see any areas that may have been missed in the initial ABCD eg wounds, areas of inflammationE-exposure (SECONDARY ASSESSMENT + INVESTIGATIONS)

History (Chest pain/SOB/palpitations/thirst/pain/fatigue/dizziness) Examine abdomen including for Neuro or other exam as indicated Input/output chart consider urinary catheter and hourly urometry Medications

CXR / ECG / ABG / Blood tests / Other investigations as indicated ABG analysis is not just for diagnosing respiratory failure it gives information on perfusion and lots of other useful things. Find out normal state ask nurses/check notes/call relative Are they an ICU/HDU candidate? If so, inform them early. Are you competent to deal with this patient by yourself?

Conclusion A B C D E

Coupled with the MINI ASSESSMENT TOOL.

Provides a structured approach to patientAssessment and a basis for further intervention / treatment

Specific Management of Some Common Emergencies

Cardiac Arrest Basic Life Support (BLS):

Call for HelpA: Head tilt + chin lift/jaw thrust. Clear mouth.B: If not breathing - give 2 breaths


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C: If no pulse - give 15 chest compressions at 100/minute, per 2 breaths.

Advanced Life Support (ALS):

If witnessed arrest - give Precordial thump.BLS.

Attach defib/monitor.If VF or pulseless-VT => DC Shock 200, 200, 360 joules; CPR 1 minute; reaccess rhythm & pulse; reshock 3 x 360 joules.If non-VF or VT-with-pulse => 3 minutes CPR; reassess rhythm & pulse.

During CPR: correct reversible causes, IV access, give 1mg IV Adrenaline each 3 minutes, consider intubation.Consider amiodarone, atropine, pacing, buffers.Reversible causes:

HypoxiaHypovolaemiaHypokalaemia, hyperkalaemiaHypothermiaTension pneumothoraxTamponadeToxic/therapeutic disturbanceThromboembolic/mechanical obstruction.

2. Myocardial Infarction

Management: (BOOMASS) Bed restOxygenOpiatesMonitor rhythm (ECG)Aspirin (300mg) (GTN and Beta-blockers can help)Steptokinase or tPA (if within 12hr and elevated ST, but no contraindications)Stop smoking (exercise, diet, physio)

In more detail:

ECG MonitorO2 (High flow)IV Access.FBP, U+E, Glucose, Lipids, Cardiac enzymes.Aspirin 300mg

Morphine (5-10mg IV) or Diamorphine (2-5mg IV) + Antiemetic, eg: Metoclopramide (10mg IV)GTN spray or Buccal Suscard (unless hypotensive)Beta-blocker (eg. atenolol 5mg IV, unless asthma or LVF)Thrombolysis (Streptokinase or Alteplase, rt-PA) - if within 12 hrs (still may help up to 24 hrs) and ST elevation, BUT no internal bleeding, no

surgery in past 2 weeks, BP not over 200/120mmHg, previous allergic reaction, pregnancy, don't give streptokinase if it is 5 days to 1 year sincelast administration. If there are thrombolysis contra-indications, consider urgent angioplasty instead.CXRProphylaxis - Management of any existing Diabetes, DVT ProphylaxisStop Calcium channel antagonists

Contraindications to Thrombolytics (Variation between clinicians these are typical):

Recent trauma/surgery Bleeding disorder Head injury Previous haemorrhagic CVA CVA within 6 months Brain tumour Active peptic ulcer Active bleeding (not menstruation) Prolonged CPR Warfarin therapy (relative C/I)

3. Acute severe Asthma

Signs of Severe attack: Cannot complete sentencesResp rate > 25/minutePulse > 110/minute


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Systolic BP < 100mmHgUrine output < 30ml/hr

If shocked: Protect airway. Nil by mouth.2 large cannulae.Draw bloods (FBP, U+E, LFT, glucose, clotting screen).Cross-match 6 units.High-flow O2.

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Project Elc 2- Tools in Assessing Critically Ill Patient