EXAM 1 CRITICAL CARE

EXAM 1 CRITICAL CARE


Critical Care
 Direct delivery of medical care within a specialized unit with specialized personnel
o Mainly for the treatment of life-threatening problems
o Levels of Care
 I: Most comprehensive, typically a teaching environment
 Staffed by specialty Drs & RNs
 II: Limited care to specialty patients
 burn units
 III: Limited availability for comprehensive critical care
 med-evac to a more comprehensive facility if out of scope for care
o Types of Units
 Open Unit
 Docs aren't ICU based, so frequent calls out occur
 multidisciplinary team is based in ICU
 Possible use of an Intensivist for patient management
 Closed Unit
 Physician collaboration
 Multidisciplinary team with an Intensivist
 Better patient outcomes than with an open unit
o Sentinel Events
 actual or potential outcomes that can cause patient harm or death
 commonplace in ICUs
o Strategies for Error Prevention
 Forcing Functions
 used to correct errors that can occur within the patient care setting
 no mixing of own meds
o done at the pharmacy level or hand delivered to the unit
 Use patient constraints
 allergy bands, fall risk identification, height or weights
 Restrict number of hours that can be worked in succession
 Use timeouts prior to procedures
 simplify processes
Ethical Principles
 Advocacy
o act on behalf of the patient foremost, then the family
 Autonomy
o patient has the right to determine what, if any medical care they may receive
 Beneficence
o duty to prevent/remove harm & promote good
 Nonmalficence
o do no harm
 Justice
o fair allocation & distribution of health resources to all

,  Confidentially
o respect for the right to control patient information
o HIPPA
CC Nurse Stressors
 Moral distress
o providing aggressive care to patients who may not benefit from it
powerlessness
o unable to find meaning in suffering
 doing invasive procedures that will not help in the end
o lots of RNs leave ICU environment r/t loss of inability to have compassion for pts
 Compassion Fatigue
o difficulty separating work from personal life
o lowered frustration tolerance
o angry outbursts
o depression
Sources of stress for patients and families
 inability to communicate related to tubes, etc
 anxiety
 sleeplessness
 delirium related to environment, lack of sleep
 pain
Communication with critically ill patients
 difficult for patient & RN
 sedation results in issues with communication
 RN must anticipate what pt needs
 use of writing tools may help with communication
Pain Management
 unpleasant sensory & emotional experience
 Predisposing factors for pain
o disease, procedures, trauma, nursing care
o Influence on pain perceptions
 expectations & previous pain experiences
 emotional & cognitive state
 Assessment Tools
o Numerical pain scoring
 0-10, with 0=no pain & 10=worst pain imaginable
o Wong-Baker faces
 useful in children and those who may not speak English well or at all
o Behavioral Pain Scale
 Facial expression (1=relaxed up to 4=grimacing)
 Upper limbs (1=no movement up to 4=permanently retracted)
 Compliance with Vent (1=tolerating movement up to 4=unable to control
ventilation)
o FLACC
 Face
 Legs

,  Activity
 Cry & Consolability
 Pharmacological Management of Pain
o Opioids (CNS)-watch for resp. depression & hypotension
 Morphine sulfate
 Potent with a rapid onset (~5m)
 drug of choice (1st line)
 inexpensive
 duration ~2h, so can be given PRN
 Fentanyl
 extremely potent with faster onset than morphine (~1-2m)
 use for acute distress or ongoing hemodynamic instability
o NSAIDs (PNS)-increases risk for GI bleeds, renal (I) or liver (A) insufficiency; decreases
need for opioid medications
 Tylenol (Acetominophen)
 Motrin (Ibuprofen)
 Toradol
 good for use as an all-over anti-inflammatory
o PCAs (patient controlled analgesia)
 Patient must be able to manage pump to be effective
 best for patients with
 elective surgery
 large surgical or traumatic wounds
 normal cognitive/motor skills
Anxiety
 prolonged state of apprehension in response to fear
 agitation, autonomic arousal, pain, sleep deprivation, noises in hospital setting
 predisposing factors
o ET tube
o alarms from monitors
o inability to move freely
o sleep deprivation
Delirium: causes and assessment.
 acutely changing mental status & inattention
o hyperactive-agitated, combative, disoriented, restless
 pt may be hard to keep in bed
o hypoactive-quiet, depression, withdrawn, flat affect, lethatgic
o mixed-fluctuation between hyper/hypo states
 sundowning
 Assessment
o CAM-ICU
 worksheet to watch for acute changes in pt
o ICDSC
 watches for disorganized thinking and decreased alertness
 Predisposing factors
o polypharmacy