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Critical Care Nursing

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  1. Critical Care Nursing Debbie L. Dempel

  2. History of Critical Care & ICU’s • 1930’s – Introduction of Recovery Rooms • WWII & Korean War – Concepts of triage and specialty nursing • Late 1950’s – beginning of Critical Care Units • Early Technology

  3. 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

  4. 1969 Educational support Certification Largest professional specialty nursing organization Scholarships Research Publishes 2 journals Local chapters Political awareness Provides standards of practice American Association of Critical-Care Nurses - AACN

  5. Critical Care Now

  6. Nursing shortage Half of patients in ICU’s >65 In US – critical care beds account for 8% of all hospital beds 20% of patients spends time in a critical care unit Downsizing Goal: provide high quality, holistic care Critical Care Now

  7. ECG monitoring Arterial Lines Oxygen Saturation Ventilation Intracranial Pressure Monitoring Temperature Pulmonary Artery Catheter IABP VAD Extensive use of pharmaceuticals Critical Care Technology

  8. The Critical Care Nurse • “Specialty dealing with human responses to life-threatening problems” • Requires Extensive Knowledge and a Continual Desire to Learn

  9. CCRN • Critical Care Certification by AACN • Requires: • Clinical hours working in an ICU • Successful completion of an exam • Requires continuing education and clinical hours for recertification

  10. Critical Care Clinical Nurse Specialist (CCNS) • Advanced practice nurse • Licensed by the State • Five Roles of a CNS: • Patient & staff educator • Consultant • Administrator • Researcher • Expert practitioner

  11. Acute Care Nurse Practitioner (ACNP) • Advanced practice nurse • Licensed by the State • Provides comprehensive care to select critically ill patients

  12. The Critical Care Patient • Physiologically Unstable • At Risk for Serious Complications • Require Intensive and Complicated Nursing Support and/or Advanced Technology

  13. Common Problems of Critical Care Patients - Nutrition • Address it early • Goal: prevent or correct nutritional deficiencies • Parenteral • Enteral

  14. Common Problems of Critical Care Patients - Anxiety • 70-80% of patients • Indicators – agitation, increased BP, increased HR, verbalization, restlessness • Treatment

  15. Common Problems of Critical Care Patients - Pain • 70% reported moderate to severe pain • 5th vital sign • Leads to anxiety, agitation, increased myocardial oxygen consumption, delays wound healing

  16. Common Problems of Critical Care Patients – Impaired Communication • Patient on the ventilator • Use of medications • Nursing Interventions

  17. Common Problems of Critical Care Patients – Sensory-Perceptual Problems • “ICU Psychosis” – Really Delirium • 15-40% of patients • Alteration in mentation • Psychomotor behavior • Alterations in sleep • Predisposing factors

  18. Common Problems of Critical Care Patients – Sleep Deprivation • Poor sleep/wake cycles • Lack of REM sleep • Predisposes patients for delirium • Treatment

  19. Family Need of the Critical Care Patient • Information – major source of anxiety and litigation • Reassurance – can reassure care is being given • Convenience – access to the patient

  20. Arterial Lines • Catheter placed in an artery • Pressure from the artery is transmitted to a transducer by a column of fluid and converted in a pressure tracing • Transducer must be placed at the Phlebostatic Axis – 4th intercostal space • Radial artery is the most common site

  21. Phlebostatic Axis

  22. Arterial Lines - Waveform • Systole – aortic valve opens, blood ejected from LV, sharp rise in waveform • Dicrotic Notch – closure of the aortic valve, signifies the beginning of diastole • Diastole – lowest point recorded on the waveform

  23. Arterial Lines - Waveform

  24. Pulmonary Artery Catheter (Swan-Ganz Catheter) • Evaluate heart disease, shock states, compromised CO, and fluid status • Also used to evaluate a patient’s response to treatment • Catheter placed through a central vein to the right atrium, right ventricle, and into the pulmonary artery

  25. Pulmonary Artery Catheter (Swan-Ganz Catheter) • Measures Intracardiac Pressures • Measures Cardiac Output • Able to Obtain Mixed Venous Blood Samples

  26. Pulmonary Artery Catheter (Swan-Ganz Catheter) • Pulmonary Artery Port • Central Venous Port • Injectate Port • Thermister Connection • Balloon Inflation Valve

  27. PA Catheter

  28. PA Catheter Insertion

  29. Preload • Volume within a cardiac chamber at the end of diastole • Pulmonary Capillary Wedge Pressure – estimates the left ventricular end-diastolic pressure, 6-12 mm Hg • Central Venous Pressure – right ventricular end-diastolic pressure, 2-8 mm Hg

  30. Afterload • Refers to the forces that oppose ventricular ejection • Systemic arterial pressure, resistance of the aortic valve, and mass and density of the blood • Systemic Vascular Resistance

  31. Cardiac Output • Volume of blood pumped by the heart in 1 minute • Normal: 4-8 L/minute • Doesn’t take into account body size • More specific is Cardiac Index – size adjusted by Body Surface Index

  32. Intraaortic Balloon Pump (IABP) • Balloon Catheter placed in the descending thoracic aortic arch • Balloon inflation timed to begin to inflate at the time the aortic valve closes – time of early diastole – dicrotic notch

  33. IABP • Augments aortic pressure and forward flow • Increases coronary perfusion • When balloon deflates at end of diastole and aortic valve opens negative pressure pulls blood forward

  34. A: Systole-balloon Deflated, facilitates Ejection of blood to Periphery B: Early diastole – Balloon begins to Inflate C: Late diastole – Balloon is totally Inflated, augments Aortic pressure & Increases coronary perfusion

  35. IABP - Goals • Support patients with inadequate CO • Support patients with inadequate BP

  36. IABP – Common Indications • Cardiogenic shock • Left ventricular failure • Cardiomyopathy • Bridge to transplant

  37. IABP - Contraindications • Aortic aneurysm • Aortic dissection • Severe PVD • Aortic Valve Insufficiency