CRITICAL CARE NURSING. Objectives After reading through this unit, you should be able to; •Describe the concepts in the management of critically ill patient. •Explain different types of critical care facilities. •Discuss admission procedure of critically ill patient. •Identify the physical, psychological and social needs of a critically ill patient. •Describe the special investigations carried out in critically ill patients. •Demonstrate competency in the management of critically ill patients. Def; •Nursing that we should give to a patient whose health is in danger or in crisis so as to save their life or prevent complications. •purpose •To maintain accurate continuous observations of the patients’ vital functions and treat or support a failing or failed biological system. it focuses on the whole body system so as to maintain health. Types of critically ill patients •Severe injuries to the head or chest. •Effect of the disease /condition on circulation ,breathing and electrolyte balance. •Unconscious patients . •Burns of second degree greater than 25% •Acute poisoning. •Respiratory failure. •Cardiovascular failure •Multiple and severe injuries of the head,chest,spine or abdominal viscera. •Acute or chronic renal failure. •Ruptured ectopic pregnancy. •Critical care facilities Acute room Termed as an acute room because of its location,equipm ents used .and the condition of the patients who are nursed there . The following equipments are found in this unit; Sunction equipment . •Oxygen administration equipments fully assembled i.e. oxygen cylinder,adminstration mask or nasal catheters, oxygen key and gauge. •Intravenous administration set. •Adequate stocks of linen. •Other requirements to include observation equipment. There should always be a nurse in acute room in the ratio of 1:2. INTENSIVE CARE UNIT A room or a unit in which a critically ill patient is being actively treated as well as monitored. Purpose; to maintain life until the precipitating Of body failure can be identified and successfully treated to allow the system to regain self control . The ratio of the nurse to the patient should be 1 nurse to 1 patient. The minimum no. of beds to establish ICU should be 4 beds. This is to merit the staffing and equipping the unit. where possible the unit should be accessible to the casualty area,labour ward, operating theatre .a delay in transfer of a critically ill patient from these areas can be critical. ETHICAL/LEGAL ISSUES IN CRITICAL CARE NURSING. •INFORMED CONSENT -implies to the right of the patient to demand, select or even refuse treatment. •Clinicians would be ethically failing in their moral duty if they take unilateral decisions in patient care, while failing to inform patient, relatives about the goal of the treatment. •The patient and relatives must be candidly and completely informed to remove ignorance while seeking medical care. this will ensure the scanty resources are used on positive goals rather than futile goals. •Integration is necessary while providing feedback to patients and relatives to avoid confusing them on the patients 'prognosis. • socio-cultural and economic factors influences perceptions and attitudes of people and hence their health care. ASSESSMENT AND ADMISSION OF THE CRITICALLY ILL PATIENT . We look at each patient as an individual with unique needs. the needs are identified through history taking, physical examination and investigations.. NB;while dealing with the critically ill patient, the evaluation and interpretation of presenting clinical signs ,assignments of life saving technique e.g. CPR and life sustaining measures are of paramount importance. history taking Past medical history ; Previous episode relevant and similar to the current problem the patient faces. Previous medical/ surgical treatments the patient may have obtained. present history The onset of the problem, when and how it started. Main presenting signs including what makes them worse. Any current medication being used. Physical examination •Identify other bio-physiological needs of the patient that might have been left out in the history •Objectives; to obtain further evidence to collaborate the history •Determine life saving and life sustaining interventions e.g. medical,surgical and the subsequent nursing care required. Investigations Objectives •Looking for actual evidence to collaborate history and examination findings. •Sign or evidence of improvement of patients’ condition during or after particular therapy. •Evidence of lack of response to the therapy being provided to the patient and providing he basis of changing the therapy Signs of severe injuries or illness •Low blood pressure •Weak peripheral pulse •Cold extremities with peripheral cyanosis •Dyspnoea • Reduced urinary output • High temperature • Palpitation • Unexplained fatigue • Chest pain. MANAGEMENT OF BURNS Assessment to include; • Age • Burn extent and depth • Presence of inhalation injury • Influence of associated illness. • Elapsed time to treatment Get a clear history of the burns, i.e. the cause which may be one of the following; • Dry heat(flames,sun) • Scalds-caused by boiling water or other liquids. • Chemicals. •Tar and bitumen •Molten metal •Electricity •Friction •Lightning, radiation. assessment. Check the airway, which is at risk of burns of the face and neck due to oedema,which can develop very rapidly. Note time of burn, to estimate mount of fluid lost . Note cause of burn e.g. is any chemical or corrosive agent still on the skin. Take the vital observations. Note any special area involved e.g. eye lids ,ears and circumfrential burns of the limbs. •Check for inhalation of smoke ,hot air, chemical fumes. •Examine for other injuries of the head, spine. •Estimate the area of the burn to asses the volume of fluid lost which requires replacement. •Estimate the depth of the burn e.g. partial thickness, full thickness which is where the dermis is destroyed and skin graft is required to avoid contractures and deformity. •Note the patient’s age. •Ask the patient’ is weight or estimate . Priorities in burn management Ensure a secure airway in burns of the face or neck, by intubation,tracheostomy. •Wash off any corrosive chemical on skin with a lot of cold water. •Remove clothes except where adherent to burned area. •Cover burn with wet sterile pads to prevent infection & for comfort. •Administer IV fluids for burns of over 10% in children and 15% in adults . WALLACE RULE OF NINES BODY AREA PER CENT% Head &neck 9% front of lower limb 9% each upper limb 9% Back of lower limb 9% Front of trunk 18% Back of trunk 18% perineum 1% In babies the head is relatively large- 15%. For full thickness burns, blood is required to replace destroyed cells The fluid volumes given and the rate of infusion are calculated from the area burned, the length of time since the burn and the patient’s weight. Fluid loss is the major cause of death in patients with major burns. In burns of over 10%,blood is taken for; • haematocrit •Hemoglobin •Urea &electrolytes. •Grouping & cross matching(for full thickness burns) Pain management •Small doses of IV morphine for severe burns •IM pethidine for less extensive burns. •Plasil to control nausea, or any other anti-emetic. •Encourage a lot of oral fluids if able to drink. if not able, a nasogastric tube s inserted or iv fluids are commenced. •Patient also requires a chest x -ray and arterial blood gas estimation. •Also check their tetanus immunity. •Take a swab for culture & sensitivity from the burned area and adjacent skin. •In major burns, a urinary catheter is inserted for monitoring of output and urine culture and sensitivity. •Elevate limbs to reduce swelling. •Aspirate large blisters under sterile conditions. •Aseptically clean and dress the burns N .b/ -use exposure method for the face, buttocks & perineum or depending with the institution’s policy.Occlsive method is used on the other body parts. burns management for the first 48 hours. In this phase, the resuscitative measures aim at combating shock due to pain and fluid loss through capillary leaking, and bleeding into the extra-cellular space. larger burns tend to produce edema involving the whole body including uninjured areas. there are direct effects on the microcirculation, including increased hydrostatic pressure, venous outflow compromise, and changes in the extra cellular space.Increasd capillary permeability is due to the production histamine and bradykinin. Fluid replacement It’s an important measure. Parkland formula ; It prescribes 4mls of ringers lactated solution per percentage burn per kilogram body weight in 24 hours. Example a patient Y sustains 30% burns and weighs 60kg,what will be his fluid requirement in 24 hours? 4mlsx30x60=7200mls in 24 hours. Calculate the rate of flow . 7200x15/24=75 drops/minute . Respiratory distress Refers to both difficulty in breathing, and to the psychological experience associated with such difficulty. causes •Asphyxia •Sepsis •Multiple trauma •Pneumonia •Hypovolaemic shock • Acute respiratory distress syndrome Bilateral infiltrates on chest X-ray ,poor oxygenation with no evidence of heart failure. ARDS is mainly due to sepsis and non-pulmonary multiple trauma ARDS is a diffuse process that includes pulmonary edema ‘on chest X-ray,decreased pulmonary compliance called “stiff lungs", refractory hypoxemia and in the late stages, pulmonary hypertension contributing factors to ARDS •Sepsis •Aspiration •Pulmonary contusion •Long bone fracture •Near drowning. clinical manifestation • interstitial pulmonary edema due to the