CH02_Care of the Critically Ill Patient.pdf

Understanding the Essentials of
Critical Care Nursing
Third Edition
Mr. mohammad
awwad
Chapter 2
Care of the Critically Ill
Patient
Copyright © 2018 Pearson Education, Inc. All Rights Reserved

Welcome message
• Welcome to the Critical Care Course! This semester, we'll be delving
into the intricacies of providing specialized care to critically ill patients.
Critical care nursing is a dynamic field that requires a deep
understanding of complex medical conditions, rapid decision-making
skills, and compassionate patient care. Throughout this course, we'll
explore topics such as advanced assessment techniques, therapeutic
interventions, and interdisciplinary collaboration. By the end of our time
together, you'll be equipped with the knowledge and confidence to
navigate the fast-paced and challenging environment of critical care
nursing.

Characteristics of Critically Ill Patients
• AACN definition
– Critically ill patients are “those patients who are at high risk for actual or
potential life threatening health problems. The more critically ill the patient
is, the more likely he or she is to be highly , unstable, and complex,
thereby requiring intense and vigilant nursing care.”
continued on next slide

Concerns of Critically Ill Patients
• Patients described the most stressful items as:
– Being in pain
– Having tubes and lines in their body that restrict their movement
– Not being able to communicate
– Being unable to fulfill family roles
– Being unable to sleep
– Not being able to control themselves
– Being thirsty

Comfort!!!
• In the realm of critical care nursing, attending to the comfort needs of
critically ill patients is foundational to providing compassionate and
effective care. Recognizing that the intensive care environment can be
overwhelming and distressing for patients, our focus extends beyond
physiological stabilization to encompass holistic comfort measures.
• From managing pain, decreasing stress, alleviating discomfort to
promoting restful sleep and maintaining optimal body positioning, optimal
nutrition, our goal is to create a healing environment where patients
feel supported, respected, and dignified.
• By addressing both physical and emotional comfort needs, we strive to
enhance patient satisfaction, promote healing, and foster a sense of
well-being amidst the challenges of critical illness.

• Communication
– Critical care nurses and ventilated patients indicate communication can
be frustrating and difficult.
– Ventilated patients need assistance with communication from their health
care providers, especially nurses.

• Communication
– Sedated Patients
 Ventilated patients who appear to be sedated and minimally
responsive have been shown to recall communication efforts of
nurses.
 Nurses see communication with ventilated patients as discouraging
because it is usually one-way.
 Patients identify the need to feel that nurses are “physically present at
the bedside.”

• Communication
– Sedated Patients
 Nurses communicate with or around their sedated patients to:
– Provide orientation or translate medical information.
– State procedural and task intentions.
– Provide reassurance.
– Apologize and/or recognize discomfort.
– Obtain a response.
– Provide intentional and unintentional distractions.
– Provide social information to colleagues.

• Communication
– Health care providers should do the following:
 Be educated about the frustration.
 Routinely ask patients about their feelings and their state of mind.
 Ask permission before beginning nursing care and procedures.
 Evaluate patients’ understanding of the information conveyed to them
by asking simple yes/no questions.
 Demonstrate attention to the needs of their patients.

• Comfort
– Unresolved pain can:
 Impair the patient’s recovery.
 Lead to anxiety.
 Interfere with sleep.
 Contribute to the stress response.
 Cause vasodilation.
 Cause other complications.

• Comfort
– Pain Assessment
 Priority should be to perform a pain assessment on a regular basis.
– At least at the beginning of every shift
– Also with each assessment of the patient
– With each adjustment of pain medication
– Most reliable indicator of pain is the patient’s self-report of pain.

• Comfort
– Pain Assessment
 Rate the intensity of the pain on a scale of 0 to 10:
– 0 being no pain at all
– 10 being the worst pain one can imagine
 Point to the location of the pain.
 Show where the pain radiates to.

• Comfort
– Pain Assessment
 Describe the characteristics of the pain.
– Is it burning or aching?
 Indicate if the patient has associated symptoms such as:
– Nausea.
– Shortness of breath.
– Dizziness.

• Comfort
– Pain Assessment
 State what aggravates the pain.
– Does it hurt more when the patient breathes?
 Consider what alleviates the pain.
– Does the pain decrease when the head of the bed is elevated?

• Comfort
– Pain Assessment
 Growing emphasis on developing behaviorally based tools for assessment of
pain.
– Facial expressions
– Body movements
– Muscle tension
– Compliance with ventilation
– Vocalization
– Physiologic parameters

• Comfort
– Pain Assessment
– Valid reliable tools include
– Critical-Care Pain Observation Tool (CPOT) : assesses pain based on
observable behaviors such as facial expressions, body movements,
muscle tension, and compliance with mechanical ventilation. The CPOT
typically consists of several items, each scored on a scale from 0 to 2 or 0
to 3, with higher scores indicating a higher level of pain.
– Behavioral Pain Scale (BPS): used in critical care settings to assess
pain in non-verbal or sedated patients who are unable to self-report their
pain levels. It evaluates pain based on observable behaviors such as
facial expressions, body movements, and vocalizations. The BPS typically
consists of several items, each scored on a scale from 0 to 4 or 1 to 4,
with higher scores indicating a higher level of pain. continued on next slide

• Comfort
– Pain Management
 Analgesics are appropriate if pain is cause of discomfort.
– Should be administered before pain develops
– Anticipation of pain is not always possible.
– Pain medication should be administered as soon as possible
after pain begins.

• Comfort
– Pain Management
 Nurse should utilize both opioid and non-opioid medications
– Work differently
– Have complementary effects.
 For moderate to severe pain critically ill patients usually experience,
IV opioids are the drugs of choice.

• Comfort
– Pain Management
 Morphine Sulfate
– Opoid
– Gold standard to which all other analgesics are compared.
– Narcotic of choice in critical care.
– Effects should be apparent within 5 minutes.
– Effects last for 1,5 to 2 hours.
• Causing vasodilation and hypotension

• Comfort
– Pain Management
 Fentanyl (Sublimaze)
– Opioid
– One hundred times more potent than morphine
– Analgesic of choice in acutely distressed patients, patients with renal
dysfunction, morphine allergy, or ongoing hemodynamic instability
– Rapid onset; within 1 to 2 minutes
– Duration of action of 1/2 to 1 hour
– Does not produce histamine release, vasodilation, or hypotension.
– Has a wider margin of safety when compared with older opioids

• Comfort
– Pain Management
 General principles for administration of pain or sedative medications
– Analgesics should be administered intravenously for immediate
onset of action.
– Subsequent doses may be given intravenously or orally on a
regular schedule around the clock.

• Comfort
– Pain Management
 General principles for administration of pain or sedative medications
– Time to reach steady state is related to duration of effect of drug,
which is measured as a half-life.
– At initiation of an infusion and when infusion rate is increased,
loading doses must be administered in order to provide
immediate analgesia and maintain desired analgesia until
infusion reaches steady state.
– In response to anticipated painful procedures the patient might
receive an additional bolus.

Drug half-life
• Drug half-life refers to the time it takes for the concentration of a drug
in the bloodstream to decrease by half.
• This concept is important because it helps healthcare providers
understand how long a drug remains active in the body and how
frequently it needs to be administered to maintain therapeutic levels.

• Comfort
– Pain Management
 Predictable situations in which medications may need to be adjusted
– Elderly patients and patients with renal insufficiency usually need
a decreased dose of medication. (decreased kidney function,
reduced liver metabolism, prolonged drug effects and an
increased risk of side effects or toxicity.)
– At the onset of therapy, until comfort is achieved, patients will
often require higher doses of pain medication.
– Post-op and post-traumatic injury pain should decrease over
time.

• Comfort
– Pain Management
 Weaning of analgesics
– Pain control has been achieved.
– Patient is not receiving neuromuscular blocking agents.
– Patient is hemodynamically stable.
– Patient is stable on the ventilator.

• Sedation: Guiding Principles
– Sedatives
 Used in the critical care setting to treat anxiety and agitation and to
provide amnesia
 Should be used only after “providing adequate analgesia and treating
reversible physiologic causes”

– Common reversible physiologic causes of anxiety and agitation include:
 Hypoxia
 Hypoglycemia
 Withdrawal
 Sleep deprivation
 Immobility
 Fear
 Most common goal is for patient to be calm, awake, or easy to arouse with
normal sleep-wake cycles.

– Sedation Assessment
 Common factors assessed across sedation scales.
– Consciousness defined as patient awareness of self and
surroundings
– Agitation defined as patient restlessness
– Anxiety defined as a “subjective feeling of distress and anguish.”
– Sleep
– Patient-ventilator synchrony defined as when there is
coordination between the respiratory movements of the patient
and the ventilator.

– Sedation Assessment
 Critical care nurse should:
– Assess the patient for pain and treat the pain prior to beginning a
sedation assessment.
– Assess the patient and administer sedation in response to
demonstrated findings on a valid, reliable scale.
• American Association of Critical-Care Nurses Sedation
Assessment Scale (SAS)
• Richmond Agitation-Sedation Scale (RASS)

– Sedation Administration
 Dose of sedatives should be:
– Titrated to a defined goal (endpoint).
– Then systematic tapering of the dose or daily interruption.
– Awakening should be instituted to minimize the effects of
prolonged sedation.

 Daily weaning of sedatives may automatically be attempted when the
patient meets the following criteria:
– Patient’s SAS or RASS is at the target level.
– Sedation is not being used to treat delirium.
– Patient is not receiving neuromuscular blocking agents.
– Patient is hemodynamically stable.
– Patient is stable on the ventilator.

 Sedatives most frequently used for ventilated patients are propofol
and dexmedetomidine.
 Patients receiving continuous infusions are likely to be oversedated
and develop complications.
 Nurses must be aware of ongoing research concerning the effects of
sedation.

– Propofol (Diprivan)
 Very short duration of action
 Indicated when sedation is required, but rapid awakening to perform
neurological assessment or extubation is necessary
 No analgesic properties; appears to provide less amnesia than
benzodiazepines.
 Onset of sedation with propofol is 40 seconds.
 Duration of 3 to 5 minutes

– Dexmedetomidine (Precedex)
 Indicated for short-term sedation of intubated patients
 Has anxiolytic, anesthetic, hypnotic, and analgesic properties.
 Rapid onset of action
 Patients who are appropriately medicated with dexmedetomidine will
be sedated but arousable.

– Dexmedetomidine (Precedex)
 Lorazepam (Ativan)
– Has antianxiety, sedative, and anticonvulsant effects
– Onset and peak effects should occur in 15 to 30 minutes
– Duration of about 8 hours

• Prevention and Treatment of Delirium
– Delirium is very common among critically ill patients
 Developing in 50% to 80% of severely ill ventilated patients
 20% to 50% of other ICU patients

– Predisposing Factors for Delirium
 Three main neurotransmitters
– Acetylcholine
– Dopamine
– Aminobutyric acid
 Dopamine normally excites the brain, whereas the other two
counterbalance the dopamine.
 Delirium probably results from an imbalance among these
neurotransmitters

– Factors that predispose critically ill patients to delirium include:
 Older age
 Preexisting alcohol or sedative misuse or withdrawal
 Preexisting dementia, depression, or psychiatric illness
 Vision or hearing impairment

 Presence of infection, especially if the patient develops sepsis
 Organ dysfunction especially congestive heart failure or renal failure
 Respiratory failure and the need for mechanical ventilation
 Pain

 Polypharmacy or the use of benzodiazepines
 Disruptions in sleep pattern
 Prolonged immobilization
 Restraints

– Prevention of delirium
 Reorienting the patient to his surroundings with each awakening
 Consistency of nurses caring
 Limiting unnecessary noise
 Providing the patient with music to filter out the noise.

– Prevention of delirium
 Removal of physical restraints as soon as possible
 Early mobilization
 ABCDE bundle includes:
– Awakening and breathing coordination
– Delirium monitoring
– Exercise/early mobility
 Avoid benzodiazepines

– Manifestations of delirium
 Sudden onset of disturbances in cognition, attention, and perception that
fluctuate over time.
 Can manifest as:
– Hyperactive (agitated)
– Hypoactive (also known as quiet and often not identified at all or
misdiagnosed as depression)
– Mixed

– Management of Delirium
 Treatment of delirium includes use of medication and environmental
and supportive strategies.
– Dosages of any medications thought to be contributing to delirium
should be decreased or the drugs discontinued.
 Quetiapine
 Haloperidol
 Dexmedetomidine

Learning Outcome 3
Describe nursing actions to meet some of the basic
physiologic needs of critically ill patients.

Basic Physiologic Needs of Critically Ill
Patients
• Sleep
– Sleep disturbances continue to be common in critically ill patients,
contributing to delirium and other sources of morbidity.
– Multitude of reasons
 Environmental factors
 Patient care activities
 Discomfort from the acute illness
 Medications
 Withdrawal from prescribed and recreational drugs

Patients
• Sleep
– Very few mechanically ventilated patients have normal sleep patterns.
 Patients in ICU average only 2 hours of sleep a day.
– Lack of sleep has been associated with both serious physiologic and
psychological effects.

Patients
• Sleep
– Majority of sleep disorders experienced by ICU patients cannot be
resolved by the use of medications alone.
– Critically ill patients suffer in particular from sleep fragmentation and
reduced restful sleep.

Patients
• Nutrition
– Nearly all critically ill patients need a dietician because they:
 Have had a cardiovascular event and should modify their diet.
 Are in renal failure and require adjustment of their diet.
 Are intubated and require enteral or parenteral nutrition.
 Have had surgery and require specialized nutrition.
 Require nutritional therapy to modulate metabolic response to stress.
 Have increased caloric and other nutritional needs following trauma or burns.

Patients
• Nutrition
– Benefits of adequate nutrition in patients include:
 Improved wound healing.
 Decreased catabolic response to injury.
 Improved gastrointestinal function.
 Reduction in complications.
 Length of hospital stay.
 Cost of stay.

Patients
• Nutrition
– Assessment
 Obtain a history.
 Review diagnostic studies.
 Assess function of the gastrointestinal tract.
 Determine nutritional requirements.

Patients
• Nutrition
– Assessment
 Essential that the nurse learn:
– The patient’s current height and weight.
• If the patient has recently lost or gained a significant amount
of weight
– Information about food allergies.
• Especially allergies to shellfish

Patients
• Nutrition
– Assessment
 Essential that the nurse learn:
– If the patient has been consuming nutritional supplements.
• Some supplements can alter the patient’s electrolyte and metabolic
balance
– If the patient has had any swallowing difficulties, nausea or vomiting, or
constipation or diarrhea.

Patients
• Nutrition
– Assessment
 Patient’s nutritional requirements must be determined.
 Calculate the patient’s caloric, protein, and fluid requirements.
 Energy requirements of critically ill, ventilated patients are usually estimated by
either a dietician or a physician.
– Formulas that calculate energy demand based on body size composition,
age, and gender.

Patients
• Nutrition
– Guidelines for Providing Nutritional Support
 Whenever possible, patients should receive oral feedings.
 Many critically ill patients are unable to eat.
 Most guidelines suggest that if a critically ill patient is unable to consume
adequate nutrition orally, nutritional support should be started within 24 to 48
hours of admission.
 Parenteral nutrition is appropriate for patients in whom it would be life
sustaining.
– Patients with short bowel syndrome, perforated gut, or a high-output
fistula.

Patients
• Nutrition
– Enteral nutrition
 Delivery of nourishment by feeding tube into GI tract
 Preferred route for nutritional supplementation
 Associated with significantly lower rates of infection than parenteral nutrition

Patients
• Nutrition
 Most common problems are:
– High gastric residual volumes.
– Bacterial colonization of the stomach.
– Increased risk of aspiration pneumonia.
– Unnecessary interruption of feeding.
• Resulting in prolonged fasting and underfeeding

Patients
• Nutrition
 Formulas are usually composed of:
– Proteins.
– Source of calories (often lactose free).
– Vitamins.
– Minerals.
– Trace elements.
– Possibly fiber.

Patients
• Nutrition
– Parenteral nutrition
 Infusion of nutrients using a venous catheter located in a large, usually central,
vein.
 Indicated in critically ill patients when nutritional supplementation is needed
and enteral feedings cannot be initiated.

Patients
• Nutrition
 Solutions usually are formulated by combining:
– Dextrose.
– Lipids.
– Protein (in the form of amino acids).
– Electrolytes.
– Water.
– Vitamins.
– Trace elements.

Patients
• Nutrition
 Major associated risks are:
– Gut mucosal atrophy.
– Overfeeding.
– Hyperglycemia.
– Increased risk of infectious complications.
– Increased mortality.

Patients
• Nutrition
 Some of the issues associated with parenteral feedings include:
– Access
– Overfeeding
– Hyperglycemia
– Hypoglycemia
– Risk of infection

Patients
• Nutrition
– Evaluation of effectiveness of nutritional therapy
 Can be monitored by:
– Determining the patient’s weight daily
– Examining the following lab studies:
• Albumin
• Hemoglobin and hematocrit
• Electrolytes, including potassium
• Magnesium
• Phosphorus
– Assessing the patient’s wounds for granulating tissue

Patients
• Mobility
– Critical care nurses have been slow to mobilize their patients.
 Perhaps fearing consequences of moving patients with multiple lines or poor
oxygen saturation
– Short-term consequences of immobility in critically ill patients include:
 Increase in ventilator-associated pneumonia.
 Delayed weaning from mechanical ventilation.
 Development of pressure ulcers.
 Delirium.

Patients
• Mobility
– Early mobilization is progressive.
 Beginning with head of the bed elevation and passive lateral turns
 Continuing to passive and active range of motion
 Movement against gravity
 Dangling and balancing
 Transferring to a chair
 Chair positioning
 Ambulating
– Physical and occupational therapists are actively involved.

Patients
• Mobility
– Critical care units that are engaged in progressive mobilization usually
have developed a protocol.
 Nurse’s role in progressive mobility depends on the protocol.
– The nurse is responsible for determining when a patient is compromised
and the activity should be halted.

Learning Outcome 4
Discuss ways to identify and meet the needs of
families of critically ill patients.

The Needs of Families of Critically Ill
Patients
• Families of critically ill patients often experience stress, anxiety, and
depression.
• Wives of patients are the most likely to be depressed.
• Families clearly have needs, and nurses are often called on to respond
to them.

Patients
• Critical Care Family Needs Inventory (CCFNI)
– Feel there is hope.
– Feel hospital personnel care about the patient.
– Have a waiting room near the patient.
– Be called at home about changes in the patient’s condition.
– Know the prognosis.

Patients
• Critical Care Family Needs Inventory (CCFNI)
– Have questions answered honestly.
– Know specific facts about the patient’s prognosis.
– Receive information about the patient at least once a day.
– Have explanations given in understandable terms.
– Be allowed to see the patient frequently.

Patients
• Needs grouped into five domains:
– Support
– Comfort
– Proximity
– Information
– Assurance

Patients
• Family members feel confused and tense as they wait until they can
gain access to information about the patient or access to the patient.
• As the patient’s critical illness progresses, the family begins searching
actively for information.

CH02_Care of the Critically Ill Patient.pdf

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