Professional Documents
Culture Documents
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
Dopamine
o Increases contractility of the heart CO is increased
o Renal dose will open up the kidney function and helps increase urine output
o At higher levels, blood pressure is increased and renal perfusion is decreased
Dobutamine
o Helps the heart pump efficiently
o Use in cardiogenic shock
Levophed
o Vasoconstriction, which helps increase blood pressure
o Long-term use can cause necrosis of the extremities fingers, toes, etc.
Nitroglycerin
o Vasodilation, which relieves chest pain
o Can give the patient a severe headache usually will give them Tylenol as well
Propofol
o Sedation
o Also helps for nausea leaves the body very quickly so it does not help the
nausea for long
o Can drop BP quickly
o Two Types
Regular
Nut based watch for nut allergies to avoid anaphylaxis
Prescedex
o Sedation
Epinephrine
o Low BP, allergic reaction
Norepenephrine/Levophed
o Shunt the blood to vital organ extremities are effected the most
Amiodorone
o Antidysmic
Hemodynamic Monitoring
Measurement of pressure, flow, and oxygenation within the cardiovascular system
o Invasive monitoring internally placed devices
o Noninvasive monitoring external devices
Values Commonly Measured in the ICU
o Systemic and pulmonary arterial pressures
o Central venous pressure (CVP)
o Pulmonary artery wedge pressure (PAWP) (also known as pulmonary artery
occlusive pressure [PAOP])
o CO/CI
o SV/SV index [SVI]
o O2 saturation of the hemoglobin of arterial blood (SaO2)
o Mixed venous oxygen saturation (SvO2)
o These measurements allow you to calculate
Resistance of the systemic and pulmonary arterial vasculature
O2 content, delivery, and consumption
Hemodynamic Terminology
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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
o 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
o Balloon may rupture, releasing air and
fragments that could embolize
o Prolonged balloon inflation may obstruct blood
flow
o Catheter may advance into a wedge position,
obstructing blood flow
o 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
o Pressure tracing will be blunted with occlusion
and will appear wedged if PA catheter advances
and becomes wedged
o Physician must reposition catheter immediately
o ALWAYS CLOSE LINE WITH CLAMP OR
STOPCOCK WHEN LINE IS
DISCONNECTED
o 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)
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
o e.g., ECG; arterial, CVP, PA, and PAWP pressures; SvO2/ScvO2
o Single hemodynamic values are rarely significant
o Monitor the whole clinical picture
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ET tube passed through mouth and vocal cords into trachea with aid of a
laryngoscope or bronchoscope
Oral intubation preferred for most emergencies b/c airway can be secured
rapidly
Uses a larger-diameter tube than nasal route, which reduces the work of
breathing (WOB) due to less airway resistance
Risks of Oral Intubation
May be difficult to place if head and neck mobility is limited
(e.g. suspected spinal cord injury)
Teeth can be chipped or dislodged during procedure
Salivation is increased and swallowing is difficult
Patient may obstruct ET tube by biting down on it
o Can use sedation along with bite block or oropharnygeal
airway to avoid this
Mouth care is a challenge due to limited space in oral cavity
o Can use smaller/pediatric-sized oral products for tooth
brushing, cleaning, & suctioning
Nasal Intubation
ET tube is placed blindly (without seeing larynx) through the nose,
nasopharynx, and vocal cords
Nasal intubation used when head and neck manipulation is risky
Once x-ray confirms proper placement, mark position of tube at lip, teeth
or nose
Obtain ABGs within 25 minutes after intubation to get oxygenation and
ventilation status
Continue pulse ox monitoring to estimate arterial oxygenation
IF PATIENT PULLS TUBE OUT, BAG THEM IMMEDIATELY
Rapid-sequence intubation (RSI)
Rapid, concurrent administration of both a paralytic and a sedative agent
during emergency airway management to decrease risk of aspiration,
combativeness, and injury to patient
NOT INDICATED IN PATIENTS WHO ARE COMATOSE OR IN
CARDIAC ARREST
Must monitor patients O status during procedure with pulse ox
Medications Often Used
What is Shock?
Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism
Imbalance in supply/demand for O2 and nutrients
Types of Shock
Cardiogenic Shock
o Systolic or diastolic dysfunction
o Compromised cardiac output (CO)
o Precipitating Causes
Myocardial infarction
Cardiomyopathy
Blunt cardiac injury
Severe systemic or pulmonary hypertension
Cardiac tamponade
Myocardial depression from metabolic problems
o Decreased filling of the ventricle will result in decreased stroke volume.
o Despite treatment, mortality rates for patients with cardiogenic shock range from
50% to 85%.
o Early manifestations
Tachycardia
Hypotension
Narrowed pulse pressure
myocardial O2 consumption
o Physical Examination
Tachypnea, pulmonary congestion (crackles, wheezes, course breathe
sounds)
Will give Lasix (push over 2 minutes), Albuterol with
Atrovent for pulmonary congestion
Want to monitor output and blood pressure after giving
Lasix
Pallor; cool, clammy skin
Decreased capillary refill time cyanosis in fingertips (if fingertips are
cool, pulse ox will not be right should be within 10 of the heart rate)
Anxiety, confusion, agitation
in pulmonary artery wedge pressure
Will have arterial line for pressures and frequent blood gases
Decreased renal perfusion and UO
o The early clinical presentation of a patient with cardiogenic shock is similar to
that of a patient with acute decompensated heart failure
o The hearts inability to pump blood forward will result in a low CO (<4 L/min)
and cardiac index (<2.5 L/min/m2)
o Tables 67-3 and 67-4 further describe the clinical presentation of a patient with
cardiogenic shock.
o Increase in PAWP heart not pumping ventricle filling LVEDP.
o Studies that are helpful in diagnosing cardiogenic shock include laboratory
studies (e.g., cardiac enzymes, troponin levels, b-type natriuretic peptide [BNP]),
electrocardiogram (ECG), chest x-ray, and echocardiogram.
o Will give Dobutamine
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Neurogenic Shock
o DISTRIBUTIVE SHOCK
o Hemodynamic phenomenon that can occur within 30 minutes of a spinal cord
injury at the fifth thoracic (T5) vertebra or above and can last up to 6 weeks.
o Can occur in response to spinal anesthesia
o Results in massive vasodilation, leading to pooling of blood in vessels
o The injury results in massive vasodilation without compensation due to the loss
of SNS vasoconstrictor tone.
o Depression of the vasomotor center of the medulla from drugs (e.g., opioids,
benzodiazepines) also can lead to decreased vasoconstrictor tone of the
peripheral blood vessels, resulting in neurogenic shock.
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o Initially, the patients skin will be warm owing to the massive dilation.
o As the heat disperses, the patient is at risk for hypothermia.
o Later, the patients skin may be cool or warm, depending on the ambient
temperature.
o Bradycardia instead of tachycardia..loss of SNS, and PS response
o Clinical Manifestations
Hypotension
Bradycardia is huge in neurogenic shock
Temperature dysregulation (resulting in heat loss)
Dry skin
Poikilothermia (taking on the temperature of the environment
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Anaphylactic Shock
o Acute, life-threatening hypersensitivity reaction
Massive vasodilation
Release of mediators
capillary permeability
o Clinical Manifestations sudden onset of symptoms
Anxiety
Confusion
Dizziness
Sense of impending doom
Chest pain
Incontinence
Swelling of the lips and tongue, angioedema
Wheezing, stridor
Flushing, pruritus, urticaria
Respiratory distress and circulatory failure
o As capillary permeability increases, fluid leaks from the vascular space into the
interstitial space
o Anaphylactic shock can lead to respiratory distress
Caused by laryngeal edema or severe bronchospasm, and circulatory
failure, due to massive vasodilation
Septic Shock
o Septic shock has three major pathophysiologic effects
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Vasodilation
Maldistribution of blood flow
Myocardial depression
Clinical Manifestations
coagulation and inflammation
fibrinolysis
Formation of microthrombi
Obstruction of microvasculature
Hyperdynamic state
Increased CO and decreased SVR
Tachypnea/hyperventilation
Temperature dysregulation
urine output
Altered neurologic status
GI dysfunction
Respiratory failure is common
Sepsis
Systemic inflammatory response to documented or suspected infection
Severe sepsis
Sepsis + Organ dysfunction
Septic shock =
Presence of sepsis with hypotension despite fluid resuscitation
Presence of tissue perfusion abnormalities
The main organisms that cause sepsis are gram-negative and gram-positive
bacteria. Parasites, fungi, and viruses can also cause the development of sepsis
and septic shock.
In as many as 10% to 30% of patients with sepsis, the causative organism is not
identified
MUST DO BLOOD CULTURE RIGHT AWAY TO ISOLATE
ORGANISM
Obstructive Shock
o Develops when physical obstruction to blood flow occurs with decreased CO
From restriction to diastolic filling of the right ventricle due to
compression
Abdominal compartment syndrome
o Patient will experience:
Decreased CO
Increased afterload
Variable left ventricular filling pressures
o Rapid assessment and immediate treatment are important.
o Pulmonary embolism and left ventricular thrombi cause an outflow obstruction as
blood leaves the right ventricle through the pulmonary artery.
o Other clinical signs include jugular vein distention and pulsus paradoxus.
Emergency Management
Stages of Shock
Usually not clinically apparent
Metabolism changes from aerobic to anaerobic.
Lactic acid build-up. ( LA is a waste product that requires oxygen for removal from the
body by the liver)
Not enough oxygen due to decreased tissue perfusion
Compensatory stage: reversible stage during which compensatory mechanisms are effective and
homeostasis is maintained.
Diagnostic Studies
Nursing Assessment
ABCs: airway, breathing, and circulation
Focused assessment of tissue perfusion
Vital signs, Peripheral pulses, Level of consciousness, Capillary refill
Skin (e.g., temperature, color, moisture), Urine output
Brief history
Events leading to shock, Onset and duration of symptoms
Details of care received before hospitalization
Allergies
Vaccinations
Nursing Process
Nursing Diagnosis or Priorities
Planning
Implementation
Evaluation
SIRS
MODS
Multiple organ dysfunction syndrome (MODS) is the failure of two or more organ
systems.
o Homeostasis cannot be maintained without intervention.
o Results from SIRS
SIRS and MODS Pathophysiology
Consequences of inflammatory response
o Release of mediators
o Direct damage to the endothelium
o Hypermetabolism
o Vasodilation leading to decreased SVR
o Increase in vascular permeability
o Activation of coagulation cascade
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Hypermetabolic state
o Hyperglycemia-hypoglycemia
o Insulin resistance
o Catabolic state
o Liver dysfunction
o Lactic acidosis
Will increase
Hematologic system
o DIC
Electrolyte imbalances
Metabolic acidosis