1. critical care

CRITICAL CARE NURSING

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CRITICAL Crucial Crisis Emergency Serious Requiring immediate action Thorough and constant observation Total dependent (Oxford Dictionary)

2Prof. Dr. R S Mehta, BPKIHS

CRITICAL CARE NURSING The care of seriously ill clients from point

of injury or illness until discharge from intensive care

Deals with human responses to life threatening problems -trauma /major surgery

(Mary,L.S., Deborah, G.K. & Marthe, J.M. 2005)


CRITICAL CARE NURSE care for clients who are very ill provide direct one to one care Responsible for making life-and death decision At high risk of injury or illness from possible

exposure to infections Communication skill is of optimal importance


CRITICALLY ILL CLIENT At high risk for actual or potential life-

threatening health problems More ill Required more intensive and careful

nursing care


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.


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.


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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The Critical Care Nurse “Specialty dealing with human responses

to life-threatening problems” Requires Extensive Knowledge and a

Continual Desire to Learn


Economic Impact of ICU (1994)

* <10% of hospital beds * 30% of acute care hospital cost * >20% of hospital budget * 1% of GNP expended for ICU care

With aging of the population Demand for critical care service will increase


Prof. Dr. R S Mehta, BPKIHS 13

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


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


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 18

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American Association of Critical-Care Nurses - AACN

1969 Educational support Certification Largest professional specialty nursing

organization Scholarships

Research Publishes 2 journals Local chapters Political awareness Provides standards of practice


An Ideal ICU


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 advocacy21Prof. Dr. R S Mehta, BPKIHS

Team Dynamics A multidisciplinary team to effectively

attain specified objective Physician team leader & critical care

nurse manager


Critical Care Practice Pattern

Open Closed transitional


Open UnitsDefinition : any attending physician with hospital

admitting privileges can be the physician of record and direct ICU care. (All other physicians are consultants)

Disadvantage : lack of a cohesive plan Inconsistent night coverage Duplication of services


Closed Units Definition: An intensivist is the physician of record for

ICU patients. (other physicians are consultants), All orders & procedures carried out by ICU staff

• advantage: • improved efficiency • standardized protocol for care• disadvantage: • potential to lock out private physician • increase physician conflict


Transitional UnitsDefinition: intensives are locally present shared co-

managed care between ICU staff and private physician

ICU staff is a final common pathway for orders and procedures

Advantage: reduce physician conflict, standard policies and

procedures usually presentDisadvantage: confusion and conflict regarding final authority &

responsibilities for patient care decision26Prof. Dr. R S Mehta, BPKIHS

ICU Model Care Full-time intensivist model :

patient care is provided by an intensivist Consultant intensivist model :

an intensivist consults for another physician to coordinate or assist in critical care, but dose not have primary responsibility for care

Multiple consultant model: multiple specialists are involved in the patient care,

(esp. R/T doctors for ventilators), but none is designated especially as the consultant intensivist

Single physician model : primary physician provides all ICU care


A Good ICU Well organized trust coordinated care• Full-time intensivist: daily round• protocol & policies (eg: how to DC elective

operation when bed not available)• bedside nurses (master degree)• no intern


A Good ICU A team: doctors, nurses, R/T, pharmacists• led by full time intensivists critical care trained available in a timely fashion (24hr/day) no competiting clinical responsibilities during duty• closed units, if resources allow


What are the conditions considered as Critical? 1. ANY PERSON WITH LIFE

THREATENING CONDITION 2. PATIENTS WITH :

ARF AMI CARDIAC TAMPONATE SEVERE SHOCK


HEART BLOCK ACUTE RENAL FAILURE POLY TRAUMA, MULTIPLE

ORGAN FAILURE AND ORGAN DYSFUNCTION

SEVERE BURNS


NURSING ASSESSMENT

IT IS THE FIRST STAGE OF NURSING PROCESS IN WHICH THE NURSE SHOULD CARRY OUT A COMPLETE AND HOLISTIC NURSING ASSESS- MENT OF EVERY PATIENT’S NEEDS, REGARDLESS OF THE REASON FOR THE ENCOUNTER.


COMPONENTS OF NURSING ASSESSMENT

1. NURSING HISTORY: Taking a nursing history prior to the physical examination allows a nurse to establish a rapport with the patient and family.

Elements of the history include – Health Status Cause of present illness including symptoms Current management of illness Past medical history including family’s medical history


Social history Perception of illness2. Psychological and Social Examination- Client’s perception Emotional health Physical health Spiritual health Intellectual health 3. Physical Examination : A nursing

assessment includes physical examination, where the observation or measurement of signs, which can be observed or measured, or symptoms such as nausea or vertigo, which can be felt by the patient. 34

The techniques used may include Inspection, Palpation, auscultation and Percussion in addition to the vital signs like temperature, pulse, respiration , BP and further examination of the body systems such as the cardiovascular or musculoskeletal systems.

Documentation of Assessment: The Assessment is documented in the patient’s medical or nursing records, which may be on paper or as part of the electronic medical record which can be assessed by all members of the health care team.


CLASSIFICATION OF CRITICAL CARE UNITS

LEVEL - I : PROVIDES MONITORING, OBSERVATION AND SHORT TERM VENTILATION. NURSE PATIENT RATIO IS 1:3 AND THE MEDICAL STAFF ARE NOT PRESENT IN THE UNIT ALL THE TIME.


LEVEL - II : PROVIDES OBSERVATION, MONITORING AND LONG TERM VENTILATION WITH RESIDENT DOCTORS. THE NURSE-PATIENT RATIO IS 1:2 AND JUNIOR MEDICAL STAFF IS AVAILABLE IN THE UNIT ALL THE TIME AND CONSULTANT MEDICAL STAFF IS AVAILABLE IF NEEDED. 37

LEVEL - III : PROVIDES ALL ASPECTS OF INTENSIVE CARE INCLUDING INVASIVE HAEMODYNAMIC MONITORING AND DIALYSIS. NURSE PATIENT RATIO IS 1:1


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 39Prof. Dr. R S Mehta, BPKIHS

HIGH DEPENDENCY CARE Coronary care units (CCU) Renal high dependency unit (HDU) Post-operative recovery room Accident and emergency departments

(A&E) Intensive care units (ICU)


TYPES OF CRITICAL CARE UNIT

NEONATAL INTENSIVE UNIT (NICU)

SPECIAL CARE NURSERY (SCN) PAEDIATRIC INTENSIVE CARE

UNIT (PICU) PSYCHIATRIC INTENSIVE UNIT

(PICU)


CORONARY CARE UNIT (CCU) CARDIAC SURGERY INTENSIVE

CARE UNIT (CSICU) CARDIOVASCULAR INTENSIVE

CARE UNIT (CVICU) MEDICAL INTENSIVE CARE UNIT

(MICU) MEDICAL SURGICAL INTENSIVE

CARE UNIT (MSICU)42Prof. Dr. R S Mehta, BPKIHS

OVERNIGHT INTENSIVE RECOVERY (OIR)

NEUROSCIENCE / NEUROTRAUMA INTENSIVE CARE UNIT (NICU)

NEURO INTENSIVE CARE UNIT (NICU)

BURN INTENSIVE CARE UNIT (BNICU)


SURGICAL INTENSIVE CARE UNIT (SICU)

TRAUMA INTENSIVE CARE UNIT (TICU)

SHOCK TRAUMA INTENSIVE CARE UNIT (STICU)

TRAUMA – NEURO CRITICAL CARE INTENSIVE CARE UNIT (TNCC)


RESPIRATORY INTENSIVE CARE UNIT (RICU)

GERIATRIC INTENSIVE CARE UNIT (GICU)


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


PRINCIPLES OF CRITICAL CARE NURSING

ANTICIPATION : The first principle in critical care is Anticipation. One has to recognize the high risk patients and anticipate the requirements, complications and be prepared to meet any emergency. Unit is properly organized in which all necessary equipments and supplies are mandatory for smooth running of the unit.


EARLY DETECTION AND PROMPT ACTION :

The prognosis of the patient depends on the early detection of variation, prompt and appropriate action to prevent or combat complication. Monitoring of cardiac respiratory function is of prime importance in assessment.


COLLABORATIVE PRACTICE : Critical Care, which has originated as technical sub-specialized body of knowledge has evolved into a comprehensive discipline requiring a very specialized body of knowledge for the physicians and nurses working in the critical care unit fosters a partnerships for decision making and ensures quality and compassionate patient care. Collaborate practice is more and more warranted for critical care more than in any other field.


COMMUNICATION : Intra professional, inter departmental and

inter personal communication has a significant importance in the smooth running of unit. Collaborative practice of communication model


Prevention of Infection : Nosocomial infection cost a lot in the health care services. Critically ill patients requiring intensive care are at a greater risk than other patients due to the immunocompromised state with the antibiotic usage and stress, invasive lines, mechanical ventilators, prolonged stay and severity of illness and environment of the critical unit itself.


Crisis Intervention and Stress Reduction : partnerships are formulated during crisis. Bonds between nurses, patients and families are stronger during hospitalization. As patient advocates, nurses assist the patient to express fear and identify their grieving patttern and provide avenues for positive coping.


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. 53Prof. 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.


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.


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. 56Prof. 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. 57

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.


CRITICAL CARE NURSE

Factors to be considered in recruiting Critical Care Nurses

are:

1. Intra and interpersonal factors2. Technical Qualifications.3. Educational background4. Clinical Experience.


PRIME RESPONSIBILITIES OF A CRITICAL CARE NURSE

Continuous monitoring Keep ready emergency trolley /

crash Cart Efficient Individualized Care. Counseling and information to

family. Application of policies and

procedures Proper records of all activities Maintain infection control

principles. Keep update with advance

information.

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QUICK REFERENCE PROTOCOL FOR MANAGING EMERGENCY IN ICU

Quickly review the patient - Identity,

History , Physical Exam. Be with the patient, ask for help. Place the patient in a suitable

position. Attach the cardiac monitor and

call for crash cart. Maintain ABC Along with expert

team Introduce IV, CV line


Administer medication as needed. Carry on Investigations - ABG, ECG, Urea, Creatinine, Blood Sugar, Cardiac enzymes. Maintain Fluid and Electrolytes . Record right things at right time rightly.


Core Competencies Patient Care Medical Knowledge Professionalism & Ethics Interpersonal Communication Skills Practice-based Learning and

Improvement Systems-based Practice


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Patient Care X X X X X X X X Medical Knowledge X X X X X X X

Practice Based Learning and Improvement X X

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Interpersonal and Communication Skills X

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Professionalism X X X X Systems-Based Practice X X X X


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Family Need of the Critical Care Patient

Information – major source of anxiety and litigation (legal issues)

Reassurance – can reassure care is being given

Convenience – access to the patient


Job description Patient care

Multidisciplinary rounds Bed allocation/triage Infection control Protocol development Quality control/assurance

Education Residents, fellows, med students, nurses, respiratory therapists,

nurse practitioners Research

Quality assurance projects Clinical trials Database-driven projects


General Concept, Setting and Principle of Critical Care Nursing


Who are critically ill patient?


Critical illness are grouped by the system of the body;

A. Cardiac System 1. Acute myocardial infarction with complications 2. Cardiogenic shock 3. Complex arrhythmias requiring close monitoring and intervention 4. Acute congestive heart failure with respiratory failure and/or

requiring hemodynamic support 5. Hypertensive emergencies 6. Unstable angina, particularly with dysrhythmias, hemodynamic

instability, or persistent chest pain 8. Cardiac tamponade or constriction with hemodynamic instability 9. Dissecting aortic aneurysms 10. Complete heart block


B. Pulmonary System . 1. Acute respiratory failure requiring ventilatory support 2. Pulmonary emboli with hemodynamic instability3. Massive hemoptysis

C. Neurologic disorder4. Intracranial hemorrhage5. Meningitis with altered mental status or respiratory

compromise 6. Central nervous system or neuromuscular disorders with

deteriorating neurologic or pulmonary function 7. Status epilepticus8. Severe head injured patients


D. Drug Ingestion and Drug Overdose 1. Hemodynamically unstable drug ingestion2. Drug ingestion with significantly altered mental

status with inadequate airway protection 3. Seizures following drug ingestion

E. Gastrointestinal Disorders4. Life threatening gastrointestinal bleeding including

hypotension, angina, continued bleeding, or with comorbid conditions

5. Hepatic failure6. Severe pancreatitis


F. Endocrine1. Diabetic ketoacidosis complicated by hemodynamic

instability, altered mental status, respiratory insufficiency, or severe acidosis

2. Severe hypercalcemia with altered mental status, requiring hemodynamic monitoring

3. Hypo or hypernatremia with seizures, altered mental status

4. Hypo or hypermagnesemia with hemodynamic compromise or dysrhythmias

5. Hypo or hyperkalemia with dysrhythmias or muscular weakness

6. Hypophosphatemia with muscular weakness


G. Surgical1. Post-operative patients requiring

hemodynamic monitoring/ventilatory support or extensive nursing care

H. Miscellaneous2. Septic shock with hemodynamic instability3. Hemodynamic monitoring4. Environmental injuries (lightning, near

drowning, hypo/hyperthermia)


Admission Criteria in ICU The ICU admission decision may be based on

several models utilizing prioritization, diagnosis, and objective parameters models.

A. Prioritization Model This system defines those that will benefit most

from the ICU (Priority 1) to those that will not benefit at all (Priority 4) from ICU admission.


Priority 1: These are critically ill, unstable patients in need of

intensive treatment and monitoring that cannot be provided outside of the ICU. Usually, these treatments include ventilator support, continuous vasoactive drug infusions. Examples of these patients may include post-operative or acute respiratory failure patients requiring mechanical ventilatory support and shock or hemodynamically unstable patients receiving invasive monitoring and/or vasoactive drugs.


Priority 2:

These patients require intensive monitoring and may potentially need immediate intervention. Examples include patients with chronic comorbid conditions who develop acute severe medical or surgical illness.


Priority 3: These unstable patients are critically ill but have a reduced likelihood of recovery because of underlying disease or nature of their acute illness. Examples include patients with metastatic malignancy complicated by infection, cardiac tamponade, or airway obstruction.

Priority 4: These are patients who are generally not appropriate for ICU admission. Admission of these patients should be on an individual basis, under unusual circumstances and at the discretion of the ICU Director. These patients can be placed in the following categories:


B. Diagnosis Model This model uses specific conditions or diseases to determine appropriateness of ICU admission. (described above in critically ill patient)


C. Objective Parameters ModelVital 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 79Prof. 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


Physical Findings (acute onset) Unequal pupils in an unconscious patient Burns covering > 10% BSA Anuria Airway obstruction Coma Continuous seizures Cyanosis Cardiac tamponade


Team of Critical Care Unit Physicians.

The Most Responsible Physician (MRP) is the physician in charge of the patient’s care during the current hospitalization. He or she communicates with other members of the team on a daily basis.

Nurses Intensive Care nurses are the minute-to-minute critical care providers. They not only help to provide, but also coordinate most aspects of care delivery. They have received specialized training in caring for critically ill patients.

Respiratory TherapistsRespiratory therapists have special training and experience in caring for patients with breathing problems. They work closely with the physician to develop a plan to support a patient’s breathing. They set up, monitor and maintain the breathing machines (mechanical ventilators), and they adjust these machines minute by minute and hour by hour to best meet the patient's needs.

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Pharmacists Pharmacists consult with the physician in selecting the right medicines at the correct dose for patients and also in monitoring drug levels in the body. Pharmacists also help to decrease medication side effects and provide valuable information to the team members.

Physical Therapist They help prevent disabilities and facilitate rehabilitation as soon as possible.

DieticiansDieticians calculate the nutritional needs of the critically ill patient and consult with the physician to provide the patient with the best possible diet, whether orally or through a feeding tube.

Medical Radiation Technologist Medical Laboratory Technologist


Trauma CoordinatorThe Trauma Coordinator reviews the plan of care for each trauma patient and in consultation with the ICU Care Team, makes suggestions regarding patient needs. She also works closely with the patient and family, and provides teaching and information to the patient and family about the patient’s progress and expected outcomes.

Social Worker Social workers provide professional assistance with the needs of patients and

families. They can help to assess and determine what resources patients and families might be lacking, providing them with information on agencies to assist with various needs and generally assisting with other family difficulties.

Clinical EducatorClinical Educators are nurses who provide ongoing education for ICU nurses on new practices, protocols and on new equipment. They are up-to-date with the best practices in ICU and communicate with the Manager and with ICU nurses about all aspects of nursing practice and education. As an important part of their role, they provide a comprehensive orientation to nurses new to the ICU Care Team as well as providing continuing advice, support and education for all nurses in ICU.

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Ward ClerkICU Ward Clerks help with communication by answering the phones, processing physician orders and coordinating some of the patient activities in the ICU.

Pastoral CareChaplains are available to minister to the spiritual needs of patients and families.

ManagerNurse Managers are nurses with additional experience and education, who are responsible for the day to day operations of the ICU. In addition to managing the ICU nursing staff, the ICU Nurse Manager is responsible for the ICU budget and nursing practices. Nurse Managers are responsible for ensuring that the care in the ICU is safe. She/he hires ICU nurses and ensures that all nursing staff members meet the standards established for their performance. She is also there to assist family members with their needs.


Thank you


ICU & CCU Service of BPKIHS

Nursing Care and Protocols


Critical Care Considerations

F=Feeding/fluid A=Analgesics S=Sedation T=Thrombolytic agents H=Head elevation U=Ulcer – bed sore G=Glucose monitoring


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


Oral feedingoHospital dieto Bland dietoNormal dieto Liquid intake


Transparenteral dieto OliclinomelIncludes:-

• Amino acid solution with electrolyte (5.5%) volume 800 ml

• Amino acid 44 gram• Na acetate• Na glycerophosphate • KCl


MgCl2 Sodium Magnesium PO4

Acetate Chloride Glucose 20% solution with CaCl2


Overall volume of TPN = 2000 ml Osmolarity = 75 mOsm/L pH = 6 Amino acid = 44 gram Total calorie = 1,215 Kcal


Fluids IV fluids like NS, RL, 5% D, 10% D, DNS


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


Morphineo Reduces painoChiefly used in MIo 2-4 mg dissolved in 10 ml NSo Antidote: Naloxoneo Supplied by hospital.


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


Sedatives

Benzodiazepines1. Midazolam

oShort acting sedatives and hypnoticsoIn intubated patientsoDose 0.01- 0.05 mg/Kg for several hours


Benzodiazepines…

2. Diazepam• Adult dose = 0.2 – 0.5 mg/ Kg• Not given in MI patients


Dissociative Anaesthesia Ketamine

Adult dose= 1 – 3 mg/kg IV


Propofolo Arousal is rapid 10- 15 minoUsed in neuro cases and those with

increased ICP, during tracheostomy procedure


Inotropes Dopamine Dobutamine Nor- adrenaline


Thrombolytic agents TEDS compressive stocking SCD (Systematic Compressive Device) LMWX Heparin flush


Head elevation Head is elevated to 30 degree.


Ulcer Two hourly position change Back care in each shift Oxygen therapy Each shift dressing of pressure sore Air mattresses


Glucose monitoring RBS as prescribed Insulin therapy Careful monitoring of signs of

Hypoglycemia(trembling, clammy skin, palpitations, anxiety, sweating, hunger, and irritability)


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


Specific equipments used in ICU and CCU

Ventilators Infusion pumps Cardiac monitors Defibrillator ABG machine ECG machine


Drugs used in CCU Aspirin Clopidogrel Nitroglycerine Atorvastatins LMWX Morphine


Sedation score in ICU is done by RASS


(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


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


“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]


Thank you…!!!


1. critical care

Education

Transcript of 1. critical care