critical care design and facilities
TRANSCRIPT
CRITICAL CARE NURSING
1Prof. Dr. Ram Sharan Mehta, MSND, CON, BPKIHS
CRITICAL Crucial Crisis Emergency Serious Requiring immediate action Thorough and constant observation Total dependent (Oxford Dictionary)
2Prof. Dr. R S Mehta, BPKIHS
DEFINITIONS
CRITICAL CARE : CRITICAL CARE IS A TERM USED TO DESCRIBE AS THE CARE OF PATIENTS WHO ARE EXTREMELY ILL AND WHOSE CLINICAL CONDITION IS UNSTABLE OR POTENTIALLY UNSTABLE.
3Prof. Dr. R S Mehta, BPKIHS
CRITICAL CARE UNIT :IT IS DEFINED AS THE UNIT IN WHICH COMPREHENSIVE CARE OF A CRITICALLY ILL PATIENT WHICH IS DEEMED TO RECOVERABLE STAGE IS CARRIED OUT.
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CRITICAL CARE NURSING :IT REFERS TO THOSE COMPREHENSIVE, SPECIALIZED AND INDIVIDUALIZED NURSING CARE SERVICES WHICH ARE RENDERED TO PATIENTS WITH LIFE THREATENING CONDITIONS AND THEIR FAMILIES.
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Critical Care Technology ECG monitoring Arterial Lines Oxygen Saturation Ventilation Intracranial Pressure Monitoring
Temperature Pulmonary Artery Catheter IABP Extensive use of pharmaceuticals
Prof. Dr. R S Mehta, BPKIHS
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Historical Background
World War II Shock wards
established for resuscitation
Transfusion practices in early stages
After World war-II, nursing shortage forced grouping of postoperative patients in recovery areas
8Prof. Dr. R S Mehta, BPKIHS
Polio epidemic 1950’s: use of
mechanical ventilation (“iron lung”) for treatment of polio
Development of respiratory intensive care units
At the same time, general ICU’s developed for sick and postoperative patients
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History Continued Collaboration between nurses and
physicians 1950’s & 1960’s – CV Disease most
common diagnosis 1960’s – 30-40% mortality rate for MI 1965 – 1st specialized ICU – The
Coronary Care Unit Emergence of Specialized ICU’s
Prof. Dr. R S Mehta, BPKIHS
1957
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ICU’s also treat the dying Isaac Asimov:
“Life is pleasant. Death is peaceful. It is the transition that is difficult”
Isaac Asimov: Professor of Biochemistry Boston 12
An Ideal ICU
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Multidisciplinary & Collaborative approach to ICU care Medical & nursing directors : co-responsibility for ICU management• a team approach : doctors, nurses, R/T, pharmacist• use of standard, protocol, guideline consistent approach to all issues• dedication to coordination and communication
for all aspects of ICU management• emphasis on research, education, ethical
issues, patient advocacy14Prof. Dr. R S Mehta, BPKIHS
CLASSIFICATION OF CRITICAL CARE PATIENTS
Level O : normal ward care Level 1: at risk of deteriorating , support
from critical care team Level 2 : more observation or
intervention, single failing organ or post operative care
Level 3; advanced respiratory support or basic respiratory support ,multiorgan failure 15Prof. Dr. R S Mehta, BPKIHS
Types of ICU General Medical Intensive Care Unit(MICU) Surgical Intensive Care Unit Medical Surgical Intensive Care Unit(MSICU)
Specialized Neonatal Intensive Care Unit(NICU) Special Care Nursery(SCN) Paediatric Intensive Care Unit(PICU) Coronary Care Unit(CCU) Cardiac Surgery Intensive Care Unit(CSICU) Neuro Surgery Intensive Care Unit(NSICU) Burn Intensive Care Unit(BICU) Trauma Intensive Care Unit
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DESIGN OF ICU
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ORGANIZATION OF ICU DESIGN OF ICU : 1. Should be at a geographically distinct area
within the hospital, with controlled access.2. There should be a single entry and exit.
However, it is required to have emergency exit points in case of emergency and disaster.
3. There should not be any through traffic of goods or hospital staff. Supply and professional traffic should be separated from public/visitor traffic. 18Prof. Dr. R S Mehta, BPKIHS
4. Safe, easy, fast transport of a critically sick pt should be a priority in planning its location. Therefore, the ICU should be located in close proximity or ER, OT, trauma ward etc.
5. Corridors, lifts and ramps should be spacious enough to provide easy movement of bed/trolley of a critically sick patient.
6. Close, easy proximity is also desirable to diagnostic facilities, blood bank, pharmacy etc.
BED STRENGTH:1. It is recommended that total bed strength in ICU
should be between 8-12 and not less than 6 or not more than 24 in any case.
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2. 3-5 beds per 100 hospital beds for a Level III ICU or 2 to 20% of the total no of hospital beds.
3. 1 isolation bed for every ICU beds.
BED AND ITS SPACE:1. 150-200 sq.ft per open bed with 8 ft in between
beds.2. 225-250 sq.ft per bed if in a single room.3. Beds should be adjustable, no head board, with
side rails and wheels.4. Keep bed 2 ft away from head wall.
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ACCESSORIES:1. 3 O2 outlets, 3 suction outlets (gastric, tracheal
and underwater seal), 2 compressed air outlets and 16 power outlets per bed.
2. Storage by each bedside.3. Hand rinse solution by each bedside.4. Equipment shelf at the head end.5. Hooks and devices to hang infusions/ blood
bags, extended from the ceiling with a sliding rail to position.
6. Infusion pumps to be mounted on stand or poles.7. Level II ICUs may require multi channel invasive
monitors. 21Prof. Dr. R S Mehta, BPKIHS
8. ventilators, infusion pumps, portable X ray unit, fluid and bed warmers, portable light, defibrillators, anaesthesia machines and difficult airway management equipments are necessary.
STAFFING :1. Medical Staff – the best senior medical staff to
be appointed as an Intensive Care Director or Intensivist. Less preferred are other specialists from anaesthesia / medicine who has clinical commitment elsewhere. Junior staff are intensive care trainers and trainees on deputation from other disciplines.
2. Nursing staff – The major teaching tertiary care ICU requires trained nurses in critical care. 22
The no of nurses ideally required for such unit is 1:1 ratio, however it might not be possible to have such members in our set up. So 1 nurse for 2 patients is acceptable. The no of trained nurses should also be worked out by the type of ICU, the workload and work statistics and type of patient load.
3.Allied Services – Respiratory services, Nutritionist, Physiotherapist, Biomedical engineer, technicians, computer programmer, clinical pharmacist, social worker / counsellor and other support staff, guards and grade IV workers.
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Design Summary: For critically ill: unstable patients Level: I II III Bed strength: ideal 8-14 Each pt. > 100 sq. ft. ( 125-150
desirable) Additional space = 100% 10% isolation bed At least 2 barriers to enter ICU
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Only one entry and exit, emergency exit Proper fire extinguisher At least 2 ft. away from head wall Central nursing station: all pt. visibleEnvironment requirements: Heating, ventilation, air-conditioning
system in ICU (HVAC system) Fully air-conditioned : 6 cycle/hr, 2 cycle
outside air Temperature = 16-25 oC
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Light: high illumination, 150 foot candle (fc), overhead light = 20fc, floor light at night = 10fc
Noise control: Under 45 dBA in day, <40 in evening, <20 in night. (watch tick= 20 & normal conversation at 55)
Furniture: solid, non-porous, stain resistant.
Floor: easy to clean and non-slippery Wall= 4-5 ft. finished with tiles Ceiling: paint with soft color, no wire lines
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Summary… Stressors in ICU:
- Patients and family stressors Staff stressors: Nurses role is to decrease stress:
examining feeling about death, listen attentively to needs, use touch therapy as applicable, family care, maintain privacy, allow cultural practices as possible.
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Core Competencies Patient Care Medical Knowledge Professionalism & Ethics Interpersonal Communication Skills Practice-based Learning and
Improvement Systems-based Practice
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Objective Parameters Model for ICU admissionVital Signs • Pulse < 40 or > 150 beats/minute• Systolic arterial pressure < 80 mm Hg or 20 mm Hg below the patient's
usual pressure • Mean arterial pressure < 60 mm Hg • Diastolic arterial pressure > 120 mm Hg • Respiratory rate > 35 breaths/minute
Laboratory Values (newly discovered)• Serum sodium < 110 mEq/L or > 170 mEq/L • Serum potassium < 2.0 mEq/L or > 7.0 mEq/L • PaO2 < 50 mm Hg pH < 7.1 or > 7.7 • Serum glucose > 800 mg/dl • Serum calcium > 15 mg/dl • Toxic level of drug or other chemical substance in a hemodynamically or
neurologically compromised patient 29Prof. Dr. R S Mehta, BPKIHS
Radiography/Ultrasonography/Tomography (newly discovered)
Cerebral vascular hemorrhage, contusion or subarachnoid hemorrhage with altered mental status or focal neurological signs
Ruptured viscera, bladder, liver, esophageal varices or uterus with hemodynamic instability
Dissecting aortic aneurysm
Electrocardiogram Myocardial infarction with complex arrhythmias,
hemodynamic instability or congestive heart failure Sustained ventricular tachycardia or ventricular fibrillation Complete heart block with hemodynamic instability
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Physical Findings (acute onset) Unequal pupils in an unconscious patient Burns covering > 10% BSA Anuria Airway obstruction Coma Continuous seizures Cyanosis Cardiac tamponade
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Functions of critical care nurse Help to restore life process: BLS/ALS Help to maintain life sustaining functions Manage crisis/ critical care situations Maintain standard: follow guidelines Maintain team spirit and IPR Ensure availability of all equipments Provide continue nursing services Maintain good rapport with family
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Thank you
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ICU & CCU Service of BPKIHS
Nursing Care and Protocols
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Critical Care Considerations
F=Feeding/fluid A=Analgesics S=Sedation T=Thrombolytic agents H=Head elevation U=Ulcer – bed sore G=Glucose monitoring
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Feeding and Fluids It includes Enteral feeding
oOro - gastric and Naso - gastric feeding oChurn dietoDairy and poultry products (Milk, egg,
youghort)oHigh protein liquid dietoMedications
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Oral feedingoHospital dieto Bland dietoNormal dieto Liquid intake
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Transparenteral dieto OliclinomelIncludes:-
• Amino acid solution with electrolyte (5.5%) volume 800 ml
• Amino acid 44 gram• Na acetate• Na glycerophosphate • KCl
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MgCl2 Sodium Magnesium PO4
Acetate Chloride Glucose 20% solution with CaCl2
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Overall volume of TPN = 2000 ml Osmolarity = 75 mOsm/L pH = 6 Amino acid = 44 gram Total calorie = 1,215 Kcal
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Fluids IV fluids like NS, RL, 5% D, 10% D, DNS
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Analgesics
Fentanylo It works 600 times more effectively than
Morphine and reduces the pain and increases the pain threshold
oUsed in moderate and severe paino In ICU 50 – 100 µg per Kgo Antidote Naloxone 0.05 mg/ Kg
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Morphineo Reduces painoChiefly used in MIo 2-4 mg dissolved in 10 ml NSo Antidote: Naloxoneo Supplied by hospital.
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Acetaminophen and NSAIDsoOften more effective than opioids in reducing
pain from pleural or pericardial rubs, a pain that responds poorly to opioids.
o particularly effective in reducing muscular and skeletal pain
o Tab form: 500mg OD
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Sedatives
Benzodiazepines1. Midazolam
oShort acting sedatives and hypnoticsoIn intubated patientsoDose 0.01- 0.05 mg/Kg for several hours
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Benzodiazepines…
2. Diazepam• Adult dose = 0.2 – 0.5 mg/ Kg• Not given in MI patients
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Dissociative Anaesthesia Ketamine
Adult dose= 1 – 3 mg/kg IV
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Propofolo Arousal is rapid 10- 15 minoUsed in neuro cases and those with
increased ICP, during tracheostomy procedure
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Inotropes Dopamine Dobutamine Nor- adrenaline
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Thrombolytic agents TEDS compressive stocking SCD (Systematic Compressive Device) LMWX Heparin flush
50Prof. Dr. R S Mehta, BPKIHS
Head elevation Head is elevated to 30 degree.
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Ulcer Two hourly position change Back care in each shift Oxygen therapy Each shift dressing of pressure sore Air mattresses
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Glucose monitoring RBS as prescribed Insulin therapy Careful monitoring of signs of
Hypoglycemia(trembling, clammy skin, palpitations, anxiety, sweating, hunger, and irritability)
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Infection control Hand washing before, during and after the procedure Sterility maintenance during procedures Use of disinfectants Weekly high wash Monthly culture test of health personnel, equipments
and infrastructures Regular inspection by infection control team Each shift CVP dressing
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Specific equipments used in ICU and CCU
Ventilators Infusion pumps Cardiac monitors Defibrillator ABG machine ECG machine
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Drugs used in CCU Aspirin Clopidogrel Nitroglycerine Atorvastatins LMWX Morphine
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Sedation score in ICU is done by RASS
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(Richmond Agitation Sedation Scale = RASS)
RASS(Richmond Agitation Sedation Scale) Number Characteristics Definition Intervention
+4 Combative Violent, immediate danger to staff
Restrain and sedate
+3 Very agitated Aggressive, pull or remove tubes
Restrain and sedate
+2 Agitated Frequent non purposeful movement, fights ventilator
Restrain and sedate
+1 Restless Anxious movement but not aggressive or vigorous
Sedate
0 Alert and calm
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Number Characteristics Definition Intervention-1 Drowsy Not fully alert but has
sustained awakening, eye contact to voice (>10 sec)
Verbal stimulation
-2 Light sedation Briefly awakens, eye contact to voice (<10sec)
Verbal stimulation
-3 Moderate sedation
Moderate or eye opening to voice but no eye contact
Verbal stimulation
-4 Deep sedation No response to voice but movement or eye opening to physical stimuli
Physical stimulation
-5 No response No response to voice or physical stimuli
Physical stimulation
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“It may seem a strange principle to enunciate (articulate) as the very first requirement in a Hospital that it should do the sick no harm.” [1859]
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MONITORING IN CRITICAL CARE AREAS…
Airway monitoring Keep talking to your patient
Breathing check Don’t forget to auscultate your patient
Circulation monitoring When in doubt check bilateral limb BP and radio-femoral delay
Disability(neurological monitoring) Keep an eye when your patients walking
Expose and look for problems Keep an eye on all tubes and wires
Pain management is must
A• ACIDOSIS• AORTIC
DISSECTION• ALCOHOL• AIRWAY
B • BREATHING• BABY
C • CIRCULATION• COMPRESSION• COOLING
D• DISABILITY• DEFIBRILLATION• TRENDELENBURG
POSITION
E• EXPOSURE• EFFUSION• EMBOLISM• ECG
TAKE HOME POINTSAlways follow ABCDIdentify and work on EWS
Thank you…!!!
65Prof. Dr. R S Mehta, BPKIHS
Guidelines for monitoring the patients in ICU: Discuss
Decrease anxiety & fear: reassure, sedation Assess: all physiological parameters Inspect & examine pt.: LOC, secretions etc. Vitals : TPR BP RR HR Pao2, paco2, urine output Weight gain Capillary refill: 3-5 sec Phy. Exam: head to toe & systematic ETT, Airway, subcutaneous emphysema, chest tube, Skin temp, gastric distention All relevant Laboratory reports: ABG, BUN, LFT etc.
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Role of Nurses in ICU
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ICU nurses play a vital role in the patient’s care, including the following:
Taking regular blood tests Changing the patient’s treatment in line with test results Giving the patient the drugs and fluids that the doctors
have prescribed Recording a patient’s blood pressure, heart rate and
oxygen levels Clearing fluid and mucus from the patient’s chest using
a suction tube Turning the patient in his or her bed every few hours to
prevent sores on the skin
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Contd… Cleaning the patient’s teeth and
moistening the mouth with a wet sponge Washing the patient in bed Changing the sheets Changing a patient’s surgical stockings,
which help circulation when he or she is inactive (lying still) for a long time
Putting drops in the patient’s eyes to make it easier to blink
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Nurses role to patient with CVP Position the patient in Semi Fowler position. Removes clothing that could constrict the
neck or upper chest Provide adequate lightening to visualize
effectively the external jugular veins. Prevent the infection from the ports by
change dressing.
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Contd… Label the date of insertion and change. Observe for complication such as
pneumothorax, hemothorax, hematoma, cardiac tamponade, air embolism and colonization of micro-organism.
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Thank you…!!!
72Prof. Dr. R S Mehta, BPKIHS