AACN Essentials of Critical Care Nursing—Pocket Handbook Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The editor and publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the editors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. AACN Essentials of Critical Care Nursing Pocket Handbook Second Edition Marianne Chulay, RN, PhD, FAAN Consultant, Critical Care Nursing and Clinical Research Gainesville, Florida Suzanne M. Burns RN, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP Professor of Nursing, Acute and Specialty Care School of Nursing Advanced Practice Nurse Level 2, Director Professional Nursing Staff Organization Research Program University of Virginia Health System Charlottesville, Virginia New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto Copyright © 2010, 2006 by The McGraw-Hill Companies, Inc. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. ISBN: 978-0-07-170273-7 MHID: 0-07-170273-3 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-166408-0, MHID: 0-07-166408-4. All trademarks are trademarks of their respective owners. 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Burns, RN, MSN, RRT, ACNP, Marianne Chulay, RN, PhD, FAAN Manager, Clinical Pharmacy Services CCRN, FAAN, FCCM, FAANP Consultant, Critical Care Nursing and Tampa General Hospital Professor of Nursing, Acute and Specialty Clinical Research Clinical Assistant Professor Care Gainesville, Florida University of Florida and Florida Advanced Practice Nuse Level 2, Director A&M University Professional Nursing Staff Organization Tampa, Florida Research Program School of Nursing University of Virginia Health System Charlottesville, Virginia v vi Carol Jacobson, RN, MN Dea Mahanes, RN, MSN, CCRN, CNRN, Robert E. St. John, MSN, RN, RRT Director, Quality Education Services CCNS Marketing Manager Seattle, Washington APN1, Nerancy Neuro-ICU Covidien Imaging & University of Virginia Health System Pharmaceutical Solutions Barbara Leeper, MN, RN, CCRN Charlottesville, Virginia Hazelwood, Missouri Clinical Nurse Specialist, Cardiovascular Services Leanna R. Miller, RN, MN, CCRN, CEN, NP Mary Fran Tracy, PhD, RN, CCRN, CCNS Baylor University Medical Center Educator for Trauma, Neuro, Flight Critical Care CNS Dallas, Texas Vanderbilt University Medical Center Fairview—University Medical Center Nashville, Tennessee Minneapolis, Minnesota Maureen Seckel, RN, APN, ACNS, BC Clinical Nurse Specialist, Medical Pulmonary Critical Care Christiana Care Health System Newark, Delaware Contents Preface / xi 2.3 Suggested Questions for Review of Past History 2.12 Peripheral Pulse Rating Scale / 21 Dedication / xii Categorized by Body System / 10 2.13 Physiologic Effects of Aging / 22 2.4 Ongoing Assessment Template / 12 Section 1. Normal Values .........................................1 2.5 Identification of Symptom Characteristics / 13 Section 3. ECG Concepts .......................................23 2.6 Chest Pain Assessment / 14 1.1 Normal Values Table / 2 3.1 ECG Lead Placement for a Three-Wire 2.7 Pain Assessment Tools Commonly Used System / 25 in Critically Ill Patients / 15 Section 2. Assessment .............................................7 3.2 ECG Lead Placement for a Five-Wire System / 27 2.8 CAM-ICU Worksheet / 16 3.3 Twelve-Lead ECG Placement / 28 2.1 Summary of Prearrival and Admission Quick 2.9 Glasgow Coma Scale / 18 3.4 Right Side ECG Chest Lead Check Assessments / 8 2.10 Sensory Dermatomes / 19 Placement / 29 2.2 Summary of Comprehensive Admission 2.11 Edema Rating Scale / 21 Assessment Requirements / 9 vii viii 3.5 Waves, Complexes, and Intervals / 30 3.16 Normal 12-Lead ECG Waves / 69 Section 4. Cardiovascular Concepts.......................83 3.6 Heart Rate Determination / 31 3.17 Normal ST Segment and T Waves / 70 4.1 Intra-Aortic Balloon Pump Frequency of 1:2 / 85 3.7 Heart Rate Determination Using the 3.18 Zones of Myocardial Ischemia, Injury, and 4.2 Intra-Aortic Balloon Pump Frequency of 1:1 / 86 Electrocardiogram Large Boxes / 32 Infarction with Associated ECG Changes / 71 4.3 Inaccurate Intra-Aortic Balloon Pump Timing / 87 3.8 Recommended Leads for Continuous ECG 3.19 ECG Patterns Associated with Myocardial 4.4 Advanced Cardiovascular Life Support (ACLS) Monitoring / 33 Ischemia / 72 Pulseless Arrest Algorithm / 89 3.9 Advantages of Common Monitoring Leads / 34 3.20 ECG Patterns Associated with Acute Myocardial 4.5 Advanced Cardiovascular Life Support (ACLS) 3.10 Evidence-Based Practice: Bedside Cardiac Injury / 73 Bradycardia Algorithm / 92 Monitoring for Arrhythmia Detection / 35 3.21 ECG Changes Associated with Myocardial 4.6 Advanced Cardiovascular Life Support (ACLS) 3.11 Evidence-Based Practice: ST-Segment Infarction / 74 Tachycardia Algorithm / 94 Monitoring / 36 3.22 Typical Plasma Profiles / 75 4.7 Problems Encountered with Arterial Catheters / 96 3.12 Cardiac Rhythms, ECG Characteristics, 3.23 Clinical Presentation of Myocardial Ischemia 4.8 Inaccurate Arterial Pressure Measurements / 98 and Treatment Guide / 37 and Infarction / 76 4.9 Pulmonary Artery Port Functions / 100 3.13 Guidelines for Management of Atrial Fibrillation 3.24 Evidence-Based Practice: Acute Coronary 4.10 Leveling of the PA Catheter / 101 and Atrial Flutter (Class I Recommendations Syndrome ST-Elevation MI and 4.11 Referencing and Zeroing the Hemodynamic Only) / 61 Non–ST-Elevation MI / 78 Monitoring System / 102 3.14 Guidelines for Management of Supraventricular Ar- 3.25 Summary of Causes of Axis Deviations / 79 4.12 Assessing Damping