Critical Care Hot Topics for the OA
Vents
Alarms and interventions, goals, restraints - using the Simple Nursing (SN) study guides
for this info
Potential causes for high-pressure ventilator alarms include the following:
• Increased secretions in the airway
• Wheezing or bronchospasm causing decreased airway size
• Displaced endotracheal or tracheostomy tube
• Obstructed ventilator tube because of water or a kink in the tube
• Patient biting the tube
Potential causes for low-pressure ventilator alarms include the following:
• Disconnection or leak in the ventilator
• Leak in the patient's airway cuff
• Patient stopped breathing
Nursing interventions for the mechanically ventilated patient in the acute care setting
include the following:
• Assessing vital signs at a minimum of every four hours
• Assessing the need for suctioning (Patients may exhibit signs of restlessness, noise
respirations, and or increased pulse and respiration rate.)
• Providing oral care every two hours at a minimum to decrease bacterial growth and
prevent ventilator associated pneumonia
• Move endotracheal tube to opposite side of mouth every 24 hours to prevent skin
breakdown
• Peptic ulcer prevention
• Deep vein thrombosis prevention
• Sedation vacation, or temporarily removing sedation when a patient is near weaning
from the ventilator as a time to assess weaning readiness (This is typically done once
per day.)
• Preventing skin breakdown by turning the patient every two hours
• Establishing methods of communication if the patient is conscious
This is what I found about restraint (in the book in the COS: page 91 and 95)
• Restraint may be required; assess need since patient is intubated - prevents accidental
extubation by patient
• To prevent unplanned extubation, provide the patient with adequate sedation and
analgesics, use soft wrist restraint only if necessary, and explain the reason for the ETT
to the patient and family members
,Pneumonia dx - maybe in regards to “ventilator associated pneumonia?” - again see SN
study guide for info ! **VAP dx = positive sputum culture, fever, chest xray (new infiltrates)
Nursing Actions to prevent VAP:
• oral care
• turn Q2hr
• chlorhexidine mouth swab Q2hr
Suctioning - SUCTION OUT, NEVER IN. 10 seconds or less, 100% oxygen 30 seconds
before, AVOID suctioning before ABG draw, avoid “routine” suctioning - only PRN.
Air embolism - place patient is reverse trendelenburg, on left side to try and trap air in right
atrium (need to double check this info but 90%)
Pneumothorax - dx, s/sx - dx: dull sounding over lung with percussion; s/sx: dyspnea,
tachycardia, tachypnea, diminished breath sounds over affected side
-open-pneumo- or “sucking sound” - treatment is to cover the wound with
“petroleum
gauze” dressing and tape ONLY 3 sides
Hemothorax - same as above info!
Treatment for Pneumo and Hemo is - chest tube
ET tube placement - interventions - reposition client Q2hrs, monitor for VAP/new
infiltrates on xray. Once the patient is intubated, endotracheal placement is verified by an end
tidal CO2 device, indicating CO2 is released in expired air from the lungs. If the tube is
inadvertently placed in the esophagus, the end-tidal CO2 is negative. The nurse also verifies
proper placement by assessing for symmetrical chest rise and fall with ventilation, equal and
bilateral lung sounds, no sounds heard over the abdomen, and an order for a portable chest x
ray to confirm placement. If lung sounds and chest wall movement are present only on the right
side of the chest, the ETT may have been placed in the right main bronchus. Right mainstem
bronchus intubation occurs because the right bronchus has a lesser angle to the trachea and is
often wider than the left bronchus. With right mainstem intubation, the ETT needs to be
repositioned and reassessed for correct placement. (pg. 87 in Ch.7 of Med-Surg book in
COS)
Ambuing a pt (?) - do they mean ambu bag?
Dosage calculations
1lb = 2.2kg,
IV dose rate calc: dose ordered/solution concentration = volume/hr
,Solution concentration: dosage in solution/volume of solution = solution
concentration Dose ordered/dose on hand = amount to administer
ICU - care of patients, complications, interventions, pt advocacy -
Shock - also see attached hemodynamics chart
Stages:
Initial stage - too little oxygen in blood to feed the organs, resulting in anaerobic metabolism
(s/sx absent in this stage)
Compensatory - HR and RR increase to get more oxygen. Sympathetic response cascade
begins and RAAs system activate to maintain BP and O2
Progressive - cold and clammy skin - starts to show s/sx and this is one of the first besides in
compensatory phase
Irreversible - Death is Imminent
POSITIONING FOR SHOCK : maintaining a flat position with the legs elevated to increase
venous return, and monitoring laboratory test results (e.g., arterial blood gases, complete blood
count). Additional interventions include maintaining body temperature and administering blood,
IV fluids, and prescribed medications.
NEURO
Subdural hematoma - can be caused by HTN, trauma,
Glascow Coma Scale - (0-15), < 8 in coma, 8 = intubate, 3 is lowest
score.
1. Eye Opening Response:
4=spontaneous
3=to verbal stimuli
2=to pain
1=none
2. Verbal Response:
5=oriented
4=confused
3=inappropriate words
2=incoherent
1=none
3. Motor Response:
6=obeys commands
5=localized pain
4=withdraws from pain
3=flexion to pain; decorticate
, 2=extension to pain; decerebrate
1=none
Total Scores:
13-15: minor brain injury
9-12: moderate brain injury
8 or less: severe brain injury
3: worse score possible:
ALS - s/sx - (pg 829 of med-surg book in COS) also known as Lou Gehrig’s disease,
is a rapidly progressing, fatal CNS (brain and spinal cord) disease that affects voluntary muscle
control. It is the most common adult-onset motor neuron disease. Amyotrophic lateral sclerosis
results in gradual degeneration and death of motor neurons, causing muscle weakness and
atrophy, but does not impair the senses or ability to think. Clinical Manifestations usually
develop after age 50, and the prevalence of ALS in the United States is 3.9 per 100,000 people.
Most people die from respiratory failure within 3 to 5 years of onset of clinical manifestations.
IICP monitoring - s/sx
Early - altered LOC, irritability, restlessness, sleepiness
Moderate - headache (constant), sudden vomiting without nausea (report to HCP). Late -
“cheyne stokes resp”, nuchal rigidity, fixed dilated pupils, babinski - toes fan out when
stimulated), Seizures, Coma, abnormal posturing
Critical Late - Cushing triad = wide pulse pressure, high BP/HTN, low HR,
Positioning for ICP
- HOB 35 degrees or higher, no flexion and bending of extremities, no coughing,
sneezing, blowing nose, no valsalva maneuvers or holding breath
CARDIAC
Vents
Alarms and interventions, goals, restraints - using the Simple Nursing (SN) study guides
for this info
Potential causes for high-pressure ventilator alarms include the following:
• Increased secretions in the airway
• Wheezing or bronchospasm causing decreased airway size
• Displaced endotracheal or tracheostomy tube
• Obstructed ventilator tube because of water or a kink in the tube
• Patient biting the tube
Potential causes for low-pressure ventilator alarms include the following:
• Disconnection or leak in the ventilator
• Leak in the patient's airway cuff
• Patient stopped breathing
Nursing interventions for the mechanically ventilated patient in the acute care setting
include the following:
• Assessing vital signs at a minimum of every four hours
• Assessing the need for suctioning (Patients may exhibit signs of restlessness, noise
respirations, and or increased pulse and respiration rate.)
• Providing oral care every two hours at a minimum to decrease bacterial growth and
prevent ventilator associated pneumonia
• Move endotracheal tube to opposite side of mouth every 24 hours to prevent skin
breakdown
• Peptic ulcer prevention
• Deep vein thrombosis prevention
• Sedation vacation, or temporarily removing sedation when a patient is near weaning
from the ventilator as a time to assess weaning readiness (This is typically done once
per day.)
• Preventing skin breakdown by turning the patient every two hours
• Establishing methods of communication if the patient is conscious
This is what I found about restraint (in the book in the COS: page 91 and 95)
• Restraint may be required; assess need since patient is intubated - prevents accidental
extubation by patient
• To prevent unplanned extubation, provide the patient with adequate sedation and
analgesics, use soft wrist restraint only if necessary, and explain the reason for the ETT
to the patient and family members
,Pneumonia dx - maybe in regards to “ventilator associated pneumonia?” - again see SN
study guide for info ! **VAP dx = positive sputum culture, fever, chest xray (new infiltrates)
Nursing Actions to prevent VAP:
• oral care
• turn Q2hr
• chlorhexidine mouth swab Q2hr
Suctioning - SUCTION OUT, NEVER IN. 10 seconds or less, 100% oxygen 30 seconds
before, AVOID suctioning before ABG draw, avoid “routine” suctioning - only PRN.
Air embolism - place patient is reverse trendelenburg, on left side to try and trap air in right
atrium (need to double check this info but 90%)
Pneumothorax - dx, s/sx - dx: dull sounding over lung with percussion; s/sx: dyspnea,
tachycardia, tachypnea, diminished breath sounds over affected side
-open-pneumo- or “sucking sound” - treatment is to cover the wound with
“petroleum
gauze” dressing and tape ONLY 3 sides
Hemothorax - same as above info!
Treatment for Pneumo and Hemo is - chest tube
ET tube placement - interventions - reposition client Q2hrs, monitor for VAP/new
infiltrates on xray. Once the patient is intubated, endotracheal placement is verified by an end
tidal CO2 device, indicating CO2 is released in expired air from the lungs. If the tube is
inadvertently placed in the esophagus, the end-tidal CO2 is negative. The nurse also verifies
proper placement by assessing for symmetrical chest rise and fall with ventilation, equal and
bilateral lung sounds, no sounds heard over the abdomen, and an order for a portable chest x
ray to confirm placement. If lung sounds and chest wall movement are present only on the right
side of the chest, the ETT may have been placed in the right main bronchus. Right mainstem
bronchus intubation occurs because the right bronchus has a lesser angle to the trachea and is
often wider than the left bronchus. With right mainstem intubation, the ETT needs to be
repositioned and reassessed for correct placement. (pg. 87 in Ch.7 of Med-Surg book in
COS)
Ambuing a pt (?) - do they mean ambu bag?
Dosage calculations
1lb = 2.2kg,
IV dose rate calc: dose ordered/solution concentration = volume/hr
,Solution concentration: dosage in solution/volume of solution = solution
concentration Dose ordered/dose on hand = amount to administer
ICU - care of patients, complications, interventions, pt advocacy -
Shock - also see attached hemodynamics chart
Stages:
Initial stage - too little oxygen in blood to feed the organs, resulting in anaerobic metabolism
(s/sx absent in this stage)
Compensatory - HR and RR increase to get more oxygen. Sympathetic response cascade
begins and RAAs system activate to maintain BP and O2
Progressive - cold and clammy skin - starts to show s/sx and this is one of the first besides in
compensatory phase
Irreversible - Death is Imminent
POSITIONING FOR SHOCK : maintaining a flat position with the legs elevated to increase
venous return, and monitoring laboratory test results (e.g., arterial blood gases, complete blood
count). Additional interventions include maintaining body temperature and administering blood,
IV fluids, and prescribed medications.
NEURO
Subdural hematoma - can be caused by HTN, trauma,
Glascow Coma Scale - (0-15), < 8 in coma, 8 = intubate, 3 is lowest
score.
1. Eye Opening Response:
4=spontaneous
3=to verbal stimuli
2=to pain
1=none
2. Verbal Response:
5=oriented
4=confused
3=inappropriate words
2=incoherent
1=none
3. Motor Response:
6=obeys commands
5=localized pain
4=withdraws from pain
3=flexion to pain; decorticate
, 2=extension to pain; decerebrate
1=none
Total Scores:
13-15: minor brain injury
9-12: moderate brain injury
8 or less: severe brain injury
3: worse score possible:
ALS - s/sx - (pg 829 of med-surg book in COS) also known as Lou Gehrig’s disease,
is a rapidly progressing, fatal CNS (brain and spinal cord) disease that affects voluntary muscle
control. It is the most common adult-onset motor neuron disease. Amyotrophic lateral sclerosis
results in gradual degeneration and death of motor neurons, causing muscle weakness and
atrophy, but does not impair the senses or ability to think. Clinical Manifestations usually
develop after age 50, and the prevalence of ALS in the United States is 3.9 per 100,000 people.
Most people die from respiratory failure within 3 to 5 years of onset of clinical manifestations.
IICP monitoring - s/sx
Early - altered LOC, irritability, restlessness, sleepiness
Moderate - headache (constant), sudden vomiting without nausea (report to HCP). Late -
“cheyne stokes resp”, nuchal rigidity, fixed dilated pupils, babinski - toes fan out when
stimulated), Seizures, Coma, abnormal posturing
Critical Late - Cushing triad = wide pulse pressure, high BP/HTN, low HR,
Positioning for ICP
- HOB 35 degrees or higher, no flexion and bending of extremities, no coughing,
sneezing, blowing nose, no valsalva maneuvers or holding breath
CARDIAC
