xxz List - medinfo2.psu.ac.thmedinfo2.psu.ac.th/~webadm/library/newbook/2014/2014-05-26/pdf/... · 12 Objective Structured Clinical Evaluation (OSCE) 12 and simulation ... 5.9 Tracheostomy

List of contributors Foreword by Julian Bion Foreword by Ged Williams

xv Preface xuii List of abbreviations xix

xxz xxiii

John W. Albarran and Annette Richardson

Importance of critical care 2 Background and classification of critically ill patients 2 National guidance 3 Evidence-based practice 3 Definitions 3 Debates on the nature of 'evidence' 5

Supporting evidence-based practice Integrated governance Using this book

References

- --- -

rchaPter 2 Competency-based practice 1

Julie Scholes, Jo Richmond and Jane Mallett

Introduction Defining competence Competence acquisition Defining the specialty Competency-based curriculum Competency and the relationship with integrated

governance

12 Assessing competence: when and how 1 2 Objective Structured Clinical Evaluation (OSCE) 12 and simulation 13 Linking the technical with humanistic care 13

References and further reading 15

Mandy Ode11

Definition Aims and indications Background

Rapid response systems Assessing and managing the deteriorating patient

ABCDE assessment process Summary

Procedure guidelines for Chapter 3

3.1 Blood pressure measurement (manual) for a patient in bed

28 3.2 Automated blood pressure measurement 28 3.3 Pulse measurement 28 3.4 Temperature measurement 2 9 31 Competency statements for Chapter 3 3 1 40 3.1 Specific procedure competency statements for

recognizing and managing the deteriorating patient

References and further reading

vi Contents

Vanessa Gibson and Karen Hill

Definition Aims and indications Background Calling for appropriate assistance

Admission of a patient to a level 2 or 3 care facility Recording status on admission Establish~ng a rapport with the patient Establishing a rapport with family and

carers


4.1 Admitting a patient to the critical care unit 4.2 Recording status on admission

52 Competency statements for Chapter 4 5 3 54 4.1 Specific procedure competency statements for

admission to the critical care unit 54

References and further readzng

Maureen Coombs, Judy Dyos, David Waters and dun Nesbr t~

Clinical Assessment 64 Interventions for the Respiratory System Chest auscultation 64 Ventilatory support

Definition 64 Indications for ventilatory support 78 Indications for chest auscultation 64 Background 79 Background 64 Non-invasive ventilation 80 Chest auscultation in cr~tical care 64 Definition of non-invasive ventilatory (NIV)

Arterial blood gas sampling 66 support 8 0 Definition 66 NIV in critical care - an overview 80 Indications for arterial blood gas sampling 66 Invasive ventilation 82 Background 66 Definition of invasive ventilator support 82 Arterial blood sampling in critical care 67 Background 8 3

Pulse oximetry 69 Invasive ventilation in critical care 83 Definition 69 Invasive ventilation modes 8 3 Indications for pulse oximetry monitoring 69 Weaning from mechanical ventilation 8 7 Background 6 9 Definition 87 Pulse oximetry in critical care 69 Aim 8 7

Airway management and care with adjunct Background 87 airways 7 1 Reduction of mechanical support 88 Definition 7 1 Extubation/decann~ilation 8 9 Aims and indications 71 Other respiratory interventions 9 0 Background 71 Intermittent positive pressure breathing (IPPB, Airway management in critical care 72 e.g. Bird, Bennett PR2) 90

Monitoring Airway Adjuncts 76 Definition 90 Partial pressure of end tidal carbon dioxide (ETC02) Indications for intermittent positive pressure

monitoring 76 breathing 90 Definition 76 Contraindications 9 0 Indications for end tidal COz monitoring 76 Complications 9 0 Background 76 Background 9 0 ETCOz monitor~ng in critical care 76 Intermittent positive pressure breathing in

Measuring endotracheaVtracheostomy tube critical care 90 cuff pressure 77 Suctioning via a tracheal tube (endotracheal or Definition 77 tracheostorny) 91 Indications for measuring endotracheaI/tracheostomy Definition 9 1

tube cuff pressure 77 A~rn and indications 9 1 Background 77 Background 92 Endotracheal/tracheostomy tubes in Suctioning through endotracheal and tracheal

critical care 78 tubes 9 3

Contents vii

Humidification Definition Aims and indications Background Humidifiers

Manual hyperinflation and hyperoxygenation Definition Aims and indications Background Manual hyperinflation and hyperoxygenation

in critical care Prone ventilation

Definition Aims and indications Background Risks of prone ventilation

Chest drains Definition Aims and indications Background Pneumothorax Pleural fluid Chest drain insertion Management of chest drains Chest drain removal

Flexible fibreoptic bronchoscopy Definition Indications for flexible bronchoscopy Contraindications and complications Background Bronchoscopy in critical care Competency and troubleshooting

Summary


5.1 Chest auscultation 5.2 Arterial puncture: radial artery 5.3 Arterial blood gas sampling: arterial cannula 5.4 Pulse oximetry 5.5 Insertion and removal of a nasopharyngeal

(NP) tube 5.6 Insertion and removal of an oropharyngeal

airway 5.7 Endotracheal tube insertion 5.8 Tracheostomy formation and tube insertion 5.9 Tracheostomy care: stoma care and dressing

changes 5.10 Inner cannula care 5.1 1 Tracheostomy removal (decannulation) 5.12 End tidal C 0 2 monitoring 5.13 Tracheal cuff pressure measurement 5.14 Continuous positive airway pressure 5.15 BiPAP 5.16 Invasive ventilator therapy care 5.17 Weaning from mechanical ventilation

5.18 Intermittent positive pressure breathing (Bird)

5.19 Endotracheal extubation 5.20 Suctioning 5.21 Humidification 5.22 Manual hyperinflation 5.23 Prone positioning 5.24 Insertion of a chest drain 5.25 Chest drain removal on a ventilated

patient

Competency statements for Chapter 5

5.1 Specific procedure competency statements for chest auscultation 147

5.2 Specific procedure competency statements for arterial blood sampling 148

5.3 Specific procedure competency statements for pulse oximetry 149

5.4 Specific procedure competency statements for nasopharyngeal airway and oropharyngeal airway 149

5.5 Specific procedure competency statements for insertion of an endotracheal tube 150

5.6 Specific procedure competency statements for tracheostorny formation and tube insertion auscultation

5.7 Specific procedure competency statements for tracheostomy removaVdecannulation

5.8 Specific procedure competency statements for end tidal COz (ETC02) monitoring

5.9 Specific procedure competency statements for tracheal cuff pressure measurement

5.10 Specific procedure competency statements for non-invasive ventilator (NIV) therapy

5.1 1 Specific procedure competency statements for invasive ventilator therapy care

5.12 Specific procedure competency statements for intermittent positive pressure breathing (IPPB) (Bird)

5.13 Specific procedure competency statements for endotracheal tube extubation

5.14 Specific procedure competency statements for suctioning

5.15 Specific procedure competency statements for humidification

5.16 Specific procedure competency statements for manual hyperinflation

5.17 Specific procedure competency statements for prone positioning

5.18 Specific procedure competency statements for insertion of a chest drain

5.19 Specific procedure competency statements for removal of a chest drain


viii Contents

Chapter 6 Monitoring of the cardiova~ular system: insertion and a~sssment

Alan 7: Platt, Sarah Conolly and Jonathan Round

Introduction Electrocardiogram monitoring

Definition Aims and indications Background The 12-lead EGG Continuous cardiac monitoring Applying ECG monitoring Assessing an ECG

Arterial blood pressure monitoring Non-invasive arterial blood pressure monitoring


Invasive arterial blood pressure monitoring Definition Aims and indications Background Evldence and current debates Insertion of and monitorlng using an invasive

blood pressure monitoring system Central venous pressure monitoring

Definition Aims and indications Background CVP trace Efficacy of CVP monitorlng Insertion of and monitoring using a CVP

monitoring system Safety and risk Issues

Advanced haemodynamic monitoring Introduction Definition Aims and indications Background

Haemodynamic monitoring The measurement of cardiac output Pulmonary thermodilution method Transpulmonary dilution method

Summary


6.1 Application of continuous ECG monitoring ~ 0 6 6.2 Setting up the arterial pressure monitoring

system and msertion of an arterial cannula 207 6.3 Setting up the CVP monitoring system and

insertion of a central venous catheter 209 6.4 Insertion of a pulmonary artery catheter

(PAC) 211 6.5 Pulmonary artery catheter monitoring 213 6.6 Undertaking pulmonary artery wedge

pressure measurement 215

6.7 Insertion of a transpulmonary cardiac output monitorine device usine lithlum dilution " (e.g. ~ i D & ~ ~ ~ l u s )

6.8 Transpulmonary cardiac output monitoring lithium dilution (e.g. LiDCOplus)

6.9 Insertion of a transpulmonary cardiac output monitoring device using thermodilution (e.g. PiCCO@)

6.10 Transpulrnonary cardiac output monitoring using thermodilution (e.g. PiCCO)

6.11 Insertion of the oesophageal Doppler probe (e.g. CardioQTM)

6.12 Oesophageal Doppler monltoring (ODM) (e.g. CardioQ)


6.1 Specific procedure competency statements for the application and use of continuous ECG monitoring

6.2 Specific procedure competency statements for insertion and use of invaslve blood pressure monitoring 225

6.3 Specific procedure competency statements for insertion and use of central pressure monltoring 226

6.4 Specific procedure competency statements for insertion of a pulmonary artery catheter 227

6.5 Specific procedure competency statements for pulmonary artery catheter monitoring 230

6.6 Specific procedure competency statements for undertaking pulmonary artery wedge pressure - measurement

6.7 Specific procedure competency statements for undertaking CO studies with a pulmonary artery catheter 234

6.8 Specific procedure competency statements for insertion of a transpulmonary cardiac output device using lithium dilution (e.g. LiDCOplus) 235

6.9 Specific procedure competency statements for transpulmonary cardiac output monitoring using lithium dilution (e.g. LiDCOplus) 237

6.10 Specific procedure competency statements for insertion of a transpulmonary cardiac output device using thermodilution (e.g. PiCCO) 23 9

6.1 1 Specific procedure competency statements for transpulmonary cardiac output monitoring using thermod~lution (e.g. PiCCO) 24 1

6.12 Speclfic procedure competency statements for insertion of an oesophageal Doppler probe (e.g, CardioQ) 243

6.13 Specific procedure competency statements for oesophageal Doppler monitoring (ODM) (e.g. CardioQ)

References

Contents ix

Kirsty Rutledge


Choice of inotrope or vasopressor Components of titration of inotropic drug therapies

Administration of inotropic drugs via syringe pumps

Titration of inotropic drugs to meet patient requirements

Changeover of inotrope and vasopressor infusions

Troubleshooting


7.1 Preparation of inotropes and vasopressors for administration via a syringe pump

7.2 Calculating dosages for the administration of inotropes and vasopressors

7.3 Administration of inotropic and vasopressor drugs via a syringe pump (commencing a new infusion)

7.4 Titration of inotropic and vasopressor drugs up and down to meet patient requirements

7.5 Changeover of inotrope and vasopressor infusions


7.1 Specific procedure competency statements for preparation of inotropes and vasopressors for clinical use 270

7.2 Specific procedure competency statements for calculating dosages for the administration of inotropes and vasopressors 271

7.3 Specific procedure competency statements for administration of inotropic and vasopressor drugs via syringe pumps 272

7.4 Specific procedure competency statements for titration of inotropic and vasopressor drugs to meet patient requirements 273

7.5 Specific procedure competency statements for changeover of inotrope and vasopressor infusions 274


:hapter 8 Assessment and support of hydration and nutrition status and care 2 77

Kirsty Rutledge and lan Nesbitt

Definition Aims and indications Background The effect of critical illness on hydration and

nutrition Optimizing hydration and nutrition

Therapy to maintain hydration and nutrition status

Maintaining fluid balance in the critically ill Maintaining nutrition

Therapy Enhanced recovery programmes Feeding critically ill patients Glycaemic control Insulin titration

Problems with providing hydration and nutrition Overfeeding Refeeding syndrome

Enteral feeding access in an intubated patient Advantages of fine-bore and

wide-bore enteral tubes Risks and complications of nasogastric tube

insertion

278 Parenteral nutrition 278 Complications 278 Ethical considerations

28 1 283 Procedure guidelines for Chapter 8

283 8.1 Blood glucose monitoring 283 8.2 Insertion of a nasogastric tube in a sedated 288 and intubated patient 290 8.3 Administration of enteral feed 290 29 1 292 Competency statements for Chapter 8 292

8.1 Specific procedure competency statements 292 for blood glucose monitoring 292 8.2 Specific procedure competency statements 293 for insertion of a nasogastric tube in an 293 intubated patient

8.3 Specific procedure competency statements 293 for administration of enteral feed

294 References and further reading

x Contents

Annette Richardson and Jayne Whatmore

Definition Aims and indications Anatomy and physiology of the kidney Acute kidney injury Indications for CCRT in acute kidney injurv Aims of CRRT

How CRRT works Principles of renal replacement therapy Continuous versus intermittent renal replacement

therapy Types of CRRT CRRT priming and treatment choices Maintaining the CRRT circuit

Assessment and monitoring of the patient on CRRT Cardiovascular status and fluid management Intravenous access and infection control Maintaining patency of intravenous access Monitoring electrolytes and metabolic status Hypothermia

Nutritional support 322 Respiratory management 322 Neurological care 323 Monitoring and problem solving on the CRRT

circuit 323


9.1 Preparation and priming of the CRRT machine 325 9.2 Commencement of CRRT 326 9.3 Managing the patient on CRRT 327 9.4 Risc~nnecti~n af C;RRT 328

Competency statement for Chapter 9

9.1 Specific procedure competency statements for CRRT

References

I Chapter 10 Assessment and monitoring of analgesia, sedation, deliriulll and ~leuromuscular blockade levels and care 333 I

Phil Laws and Nicola Rudall

Pain Definitions Aims and indications Background Anatomy and physiology Assessment of pain Management of pain

Sedation Definition Aims of sedation Background Sedation hold Withdrawal of sedation Rescue sedation Assessment of sedation Monitoring of sedated patients

Delirium Definition Aims in treating patients with, or at risk of

developing, delirium Background Drugs and delirium Assessment and monitoring of delirium

Neuromuscular blockade Definition Aims and indications Anatomy and physiology Neuromuscular blockade Assessment of neuromuscular blockade

Treatment 342 Drugs for sedation, analgesia and neuromuscular

blockade 342 Sedation 342 Analgesia 345 Opioids 345 Neuromuscular blockade 345 Rescue sedation 346


10.1 Assessment of pain 10.2 Sedation management: sedation holds and

titration 10.3 Assessing delirium 10.4 Neuromuscular blockade assessment


10.1 Specific procedure competency statements for assessment of pain

10.2 Specific procedure competency statements for sedation management: sedation holds and titration

10.3 Specific procedure competency statements for assessing delirium

10.4 Specific procedure competency statements for neuromuscular blockade assessment


Contents xi

--- - Chapter 11 Assessment and monitoring of neurological status 357 1

Margaret A. Douglas and Sarah E.C. Platt

Definition Aims and indications Background anatomy and physiology of

the central nervous system Assessment of neurological status

Clinical methods Invasive monitoring

ICP monitoring devices Aspects of care impacting on intracranial pressure Advanced neuromonitoring


11.1 Neurological observations and assessment 11.2 Recording intracranial pressure from an

intracranial pressure monitor that incorporates an external ventricular drain (EVD)

11.3 Recalibrating (zeroing) an intracranial pressure monitor that incorporates an external ventricular drain (EVD)


11.1 Specific procedure competency statements for recording intracranial pressure from an intracranial pressure monitor that incorporates an external ventricular drain (EVD)

11.2 Specific procedure competency statements for recalibrating (zeroing) an intracranial pressure monitor that incorporates an external ventricular drain (EVD)

References 3 74

Chapter 12 Assessment and care of tissue viability, and mouth and eye hygiene needs 381 1 -- - - -- --

Philip Woodrow, Judy Elliott and Pauline Beldon

viability Definition Indications Anatomy and physiology Functions of the skin Challenges to health of skin

Pressure ulcers Definition Indications Background Pressure ulcer grading Extrinsic factors Assessment Skin inspection Prevention Healing pressure ulcers Dressings Reporting pressure ulcers Conclusion Useful websites

Mouth care Definition Aims and indications Background Anatomy and physiology Oral pathophysiology Problems in critical illness Assessment and care of oral cavity Dentures

Eye care Definition Aims and indications

Background Anatomy and physiology Problems Assessment and care

382 382 382 3 82 383 3 84 384 Procedure guidelines for Chapter 12 384 384 12.1 Assessment of oral cavity 384 12.2 Care of the oral cavity 385 12.3 Denture hygiene 386 12.4 Assessing the eye 386 12.5 Cleansing the eyes 386 12.6 Instillation of eye drops 387 390 390 Competency statements for Chapter 12 390 390 12.1 Specific procedure competency statements 3 90 for pressure ulcer prevention 390 12.2 Specific procedure competency statements 3 90 for assessing and managing pressure ulcers 397 in patients who are critically ill 397 12.3 Specific procedure competency statements 397 for mouth care for critically ill patients 398 12.4 Specific procedure competency statements 398 for eye care for critically ill patients 399 400 References and further reading 400 400 400

xii Contents

Annette Richardson, Micheala Allsop and Elaine Coghill

Definition Indications Background The stages of sleep Why is sleep important?

Assessment of sleep Physiological sleep assessment methods Non-physiological sleep assessment

methods Non-physiological sleep assessment tools

Factors that disrupt and promote sleep

Procedure guideline for Chapter 13

13.1 Sleep assessment and promotion


13.1 Specific procedure competency statements for sleep assessment

13.2 Specific procedure competency statements for sleep promotion


1 Lhapter 14 Yhyslcal mobi~lty and exerclse interventions tor crit~cally 111 patlents 4.33 1

D.J. McWilliams and Amanda Thomas

Definitions Aims and indications Background anatomy and physiology Evidence and current debates

Review of components of physical mobility and exercise Assessment of readiness to mobilize

Interventions During the acute phases of illness Rehabilitation for patients unable

to sit on the edge of the bed (i.e. 'bed bound')

Rehabilitation for patients deemed ready to sit on the edge of the bed

Post-critical care rehabilitation Measurement of manual handling risk


14.1 Positioning a patient in high sitting 447 14.2 Positioning a patient in high side lying 448 14.3 Positioning a patient in side lying 450 14.4 Positioning a patient with raised intracranial

pressure (30" tilt) 451

14.5 Log rolling a patient with suspected spinal injury to lay on their right side

14.6 Positioning a patient for a chest X-ray 14.7 Mechanical hoist transfer


14.1 Specific procedure competency statements for positioning a patient in high sitting

14.2 Specific procedure competency statements for positioning a patient in high side lying

438 14.3 Specific procedure competency statements for positioning a patient in side lying

442 14.4 Specific procedure competency statements 444 for positioning a patient with raised 444 intracranial pressure 462

14.5 Specific procedure competency statements for log rolling a patient with a suspected spinal injury 463

14.6 Specific procedure competency statements for positioning a patient for a chest X-ray 464

14.7 Specific procedure competency statements for completing a hoist transfer


Andrew Baker and Simon M. Whiteley

Definitions Aims Indications Background

Physiological effects of transfer Cardiovascular system Effect of movement/gravitational forces Respiratory system

The effects of altitude: potential for hypoxia 471

The effects of altitude: expansion of air spaces 473 Physiological stress response 473 Temperature control 473

Evidence and current debates 473 Quality of patient transfers 473 Organization 474

Contents xiii

Role of critical care networks Specialist transfer teams Timing of transfers

Components of the transfer process The decision to transfer Communication Assessment and stabilization prior

to transfer Selection of transport mode Preparation for transfer Safe transfer Handover

Competency statements Guidelines for transfer

Equipment


15.1 Decision to transfer 479 15.2 Communication 479 15.3 Assessment and stabilization prior to transfer 480

15.4 Preparation for transfer 15.5 Carrying out safe transfer 15.6 Handover


15.1 Specific procedure competency statements for decision making in relation to transfer 484

15.2 Specific procedure competency statements for communication in relation to transfer 485

15.3 Specific procedure competency statements for assessment and stabilization prior to transfer 485

15.4 Specific procedure competency statements for preparation for transfer 486

15.5 Specific procedure competency statements for carrying out safe transfer 486

15.6 Specific procedure competency statements for handover following patient transfer 487


Catherine I . Plowright and Christina Jones

Definition Aims and indications for rehabilitation Background Rehabilitation and critical care Effect of critical illness on patients' families

Review of components of rehabilitation Gom critical care Muscle loss and weakness Cognitive deficits Rehabilitation

Rehabilitation interventions Diaries Counselling

Summary

490 Procedure guideline for Chapter 16 490 490 16.1 Rehabilitation during and following critical

490 illness 490

491 Competency statement for Chapter 16 491 491 16.1 Specific procedure competency statements for

492 rehabilitation of critically ill patients 495 492 493 References 497 493 Usehl websites 498

493

Natalie A. Pattison


Pre-EOLC considerations: at the beginning Prognosis Post prognosis: EOLC in critical care environments

Tools that facilitate best care at EOL Guidance for EOLC Assessment of need for 'Do Not Attempt

Cardiopulmonary Resuscitation' orders Process for obtaining a DNACPR order Assessment of need for discussion of withdrawal

of treatment

Avoiding prolongation of dying and decisions about transfer

Care around withdrawal: care in the last days and hours Diagnosing dying

Consultation and communication of decision to withdraw treatment with patient, next of kin and significant others 506 Patients 506 FamiliesAVext of kinlsignificant others 506 Nurses and allied health professionals 507

Communication and breaking bad news: supporting the family 507

xiv Contents

Cultural issues Review of practical components of withdrawal of

treatment and end of life care When to withdraw How and when to withdraw treatment Extubation Care of the dying patient during extubation Further EOLC considerations in the last days

and hours Sudden or unexpected dying

Brainstem function measurement and death Brainstem death

After-death care Communicating procedures around death Preparing the body of the patient who has died Considerations before showing families the deceased

patient (either before or after last offices) Families' time with patient in unit after the

patient's death Bereavement care

Competencies Conclusion

Procedure guidelines for Chapter 1 7

17.1 Communication strategies at end of life 17.2 Considerations concerning withdrawal of

treatment 17.3 Extubation care at end of life 17.4 Considerations for end of life care for

patients in critical care units 17.5 Summary of procedures after death

Competency statement for Chapter 17

17.1 Specific procedure competency statements for end of life care

References and further reading Useful websites

Jackie S. Younker and Jasmeet Soar

Identifying reversible causes Post-cardiac arrest care Diagnosing death

Definition Aims and indications Background Anatomy and physiology Incidence and causes of cardiac arrest

Evidence for guidelines In-hospital resuscitation

Location Skills of the staff who respond to the cardiac

arrest Number of responders Equipment and medicines available Resuscitation team

Initial management of the 'collapsed' patient Personal safety Recognizing cardiac arrest and calling for help Starting CPR High-quality chest compressions Airway and ventilation Defibrillation Drugs and vascular access

Procedure guideline for Chapter 18

18.1 Resuscitation


18.1 Specific procedure competency statements for recognition of cardiac arrest and starting CPR 548

18.2 Specific procedure competency statements for defibrillation - AED 549

18.3 Specific procedure competency statements for defibrillation - manual 549

18.4 Specific procedure competency statements for airway assessment and ventilation 550

References Useful websites

Index

Documents

xxz List - medinfo2.psu.ac.thmedinfo2.psu.ac.th/~webadm/library/newbook/2014/2014-05-26/pdf/... · 12 Objective Structured Clinical Evaluation (OSCE) 12 and simulation ... 5.9 Tracheostomy