CARING FOR CRITICALLY ILL PATIENT Legal Relationships Nurses duty MYOCARDIAL INFARCTION (MI)

Nurse-employer Competent & able to

Role of a Critical Care Nurse follow policies and Definition:
 Provide care direct to the patient. procedures. Irreversible myocardial necrosis due to sudden
 Involve family members in patient’s care. Nurse-patient Give reasonable and decrease or total stop of coronary blood flow to a
 Facilitate communication among healthcare careful care specific area of myocardium.
provider, patient, and family. Nurse-law Provide safe and
 Provide appropriate intervention & actions. competent practice as Pathophysiology
 Formulate patient care goals. defined by the standard Cholesterol deposited on
 Ensure patient safety: artery wall forming plagues
 Identify patient correctly and causes it to harden and
Patient Care Issues
narrows the lumen.
 Improve communication among staffs.  Consent must be voluntary and informed
 Use medication safely.  Person giving consent must be:
 Prevent infection.  Legally competent The plagues may rupture and
 Identify patient safety risks  Adult blood clot form on the surface of
 Prevent mistakes in surgery.  Mentally stable the plague.
 Have capacity (reasoning)
ETHICAL & LEGAL ISSUES  Patient can refuse treatment.
 If patient is not for resuscitation, DNR order The clot blocks the blood
Autonomy should be documented by doctor. flow and causes MI.
 Freedom to make decision without others  The doctor should explain everything to the
interference. patient about diagnosis and treatment.
 Critical care nurse act as patient advocate Oxygen delivery is affected and cause
before patient and family make decision: due to the thrombosis or spasm close
PATIENT & FAMILY EDUCATION
 Provide information to the rupture plague
 Clarify points Nurses responsibility
 Reinforce information  Assess patient & family learning needs. Clinical Manifestation
 Provide support  Education must be ongoing, interactive, and Chest pain squeezing in nature radiating to
consistent with the education level. left arm, jaw or upper back
Beneficence  Reduce stress, anxiety, and fear first. Shortness of breath Nausea & vomiting
 Promote wellbeing by considering harms and  Focus on orientation of environment & Heartburn Sweating
benefits, leading to positive outcome. equipment, procedure explanation, and General malaise STEMI/ NSTEMI
immediate plan of care.
Non-maleficence  Ensure patient is emotionally stable. Risk Factors
 Prevent harm and correct harmful situation. Hyperlipidemia Diabetes
Learning Needs Smoking Male
Veracity  Orientation of various care providers & Family history Obesity
 Truth telling in information given. services available.
 Important in requesting informed consent  Orientation on environment (eg: call bell) Types of MI
because patient need to be aware about the  Orientation on unit rutines and care plan
risks and benefits. (visiting hour, monitoring, daily weight) Anterior MI
 Explanation on equipments, monitors &
•Occlusion of proximal left anterior
Fidelity associates alarms (eg: ventilator) descending artery
 Requires loyalty, fairness, truthfulness,  Explanation on procedures & expected
•ST-elevation in lead V1-V4
advocacy, and dedication outcomes.
•Most dangerous MI
 Information on medication (name, indication,
Justice side effects) and reporting to nurse. Left Lateral MI
 Refers to an equal and fair distribution of  Immediate plan of care
resources, based on analysis of benefits and  Transition to next level of care: transferring, •Occlusion of circumflex coronary artery
burdens of decision. staffs, environment •New Q waves & ST-elevation in leads I, aVL.
 Discharge plan (medication, diet, activity) V 5, V 6
Elements in Code of Ethics Inferior MI
 The professional code of ethics Successful Education
Values and relationship among members of the  Attention •Occlusion of right coronary artery
profession and society. The information must be important to know. •Distiurb blood supply to SA & AV nodes,
 The purpose of the profession  Simple and Bundle of His (proximal part)
The need of profession to provide certain Use everyday language & avoid medical terms •High mortality if Rt ventricle affected.
duties formed between nursing and society  Time
Right Ventricular MI
 The standards of practice of the professional Be present when teaching.
Describe specifics of practice in variety of  Reinforce •Occlusion of the proximal part of Rt
settings and subspecialties. Provide positive rewards to patient. coronary artery
•Can affect right ventricle and inferior wall
Steps in ethical decision making Special Consideration for:
 Identify the health problem 1. Older adult Posterior MI
 Define the ethical issue 2. Sedated or unconscious patient •Occlusion in Rt coronary artery or
 Gather additional information 3. Illiterate patient circumflex artery
 Outline the decision maker 4. Noncompliant patient •Tall R waves can be seen in leads V1, V2
 Examine ethical & moral principles
 Explore alternative options
 Implement decisions
 Evaluate & modify actions
 Diagnostic Test CORONARY ARTERY DISEASE (CAD) Types of Heart Failure
I. 12-lead ECG Left Ventricular Failure (LVF)
 ST-segment (elevated/ not elevated) Definition: •Disturbance of contractility of left ventricle
If NSTEMI, necrosis is not full thickness Hardening of the coronary arteries, this may •Results in low CO, increase afterload &
 Q wave present cause angina pectoris and lead to myocardial vascular resistance, and pulmonary edema
II. Cardiac enzyme or biomarkers infarction.
•Symptoms: Tachypnea, tachycardia, cough
 CK-MB (rise 3-12 hrs, peak at 24 hrs,
Right Ventricular Failure (RVF)
remain elevated for 2-3 days) Clinical manifestation
•Disturbance of contractility of right
 Trop-I (rise 3-12 hrs, peak at 24 hrs, remain Chest pain/discomfort at arms, jaw, neck
ventricle
elevated for 2-3 days) Shortness of breath Lightheaded
•Due to acute condition like pulmonary
 Trop-T (rise 3-12 hrs, peak at 12-48 hrs, Sweating Nausea and vomiting
embolus and right ventricle infarction.
remain elevated 5-14 days)
•Symptoms: Peripheral edema, high CVP,
III. Chest X-ray Risk Factors weakness, jugular venous distention
Middle to old age Male Systolic Heart Failure
Treatment Family history Hyperlipidemia
a) Reopening of the coronary artery Obesity Hypertension •Abnormality of heart muscle that decrease
-Fibrinolytic therapy contractility during systolic & reduse
Smoking Diabetes
quantity of blood that can be pumped out.
-Percutaneous Catheter Intervention (PCI) Chronic Kidney disease Post-menopause
b)Anticoagulation •Symptoms: Dysnea, fluid overload,
exercise intolerance.
-IV Heparin bolus with fibrinolytic therapy
c) Pain control Diastolic Heart Failure
Types of angina
-SL Nitroglycerin 1 tab (0.04mg) every 5 mins •Abnormality in heart muscle making it
Stable Angina Unstable Angina
-IV Morphine 2-4mg unable to rest, stretch or fill during
• Cause by the same • Cause by change in diastolic.
-Non-coated Aspirin 162-325mg
precipitating pattern of stable •Ejection fraction may be normal or low.
-Oxygen therapy maintain >90%
factors each time angina
d)Dysrhythmias prevention Congestive Heart Failure
(eg: exercise)
-IV Amiodarone
• Pain reduce by rest • Pain need more •Determined by rapidity of syndrome
-Beta blocker reduce heart rate
and taking S/L GTN than rest & GTN. A develops, presents of compensatory
e) Glucose control mechanism & presence of fluid
medical
f) Prevention of ventricular remodelling accumulation.
emergency
-ACE inhibitor/ ARB reduce risk of heart failure •In acute, it is sudden onset with no
• Due to 75 blockage • Due to plague
of coronary artery. instability & can compensatory mechanism.
Complications of MI •In chronic HF, symptoms may be tolerable
cause MI
 Related to electrical dysfunction with medication, diet & activity level.
 New murmur
 Bradycardia Management:
 Bundle branch block Management: Medical
 Heart block  Accurate assessment of chest pain to  Pulmonary Artery Catheter (PAC) to monitor
 Related to contractility differentiate unstable & stable angina. left ventricle function
 Heart failure  Recognize myocardial ischemia by intensity of  Administer diuretics & fluid restriction to
 Pulmonary edema pain, vital signs, 12-lead ECG, and immediate prevent fluid overload.
 Cardiogenic shock fibrinolytic & heparin administered or PCI are  Serve Morphine to reduce anxiety &
performed to detect obstruction. facilitate peripheral dilatation
Nursing Management  Relieve chest pain by giving oxygen,
 Serve vasodilator (nitroglycerin) to reduce
 Preventing complication nitroglycerin, analgesics, and aspirin.
preload & dilate coronary arteries.
-Manage and alleviate chest pain  Maintain calm environment to reduce anxiety
 Intra-aortic Balloon Pump (IABP) to support
-Assess and reduce anxiety  Patient education:
inadequate CO and blood pressure.
-Monitor lab result (esp. K and Mg to prevent -Alert nurse for any chest pain or discomfort
 Administer inotropic (dopamine) to increase
arrhythmia) -Avoid straining
contractility.
-Monitor ST-segment continuously -Risk factor modification
 Administer ACEi to inhibit ventricular
-Monitor signs of arrhythmia -Identify signs & symptoms of angina
remodelling slows ventricular dilation.
-Monitor arterial oxygen saturation -Importance of medication
 Administer Beta blocker (carvedilol) to
-Create plan for patient’s physical activity -When to call doctors/seek treatment
-Emotion & stress management reduce heart rate
-Assess signs of heart failure (pedal edema)  Serve Digoxin to control Atrial Fibrillation
-Assess heart sound for new murmur.  Permanent pacemaker
-Monitor patient for drug compliance HEART FAILURE
-Give stool softener to prevent straining.
Definition: Nursing
 Patient education
-Eat variety of fruit and veggies, limit amount A condition in which the heart cannot pump  Optimizing cardiopulmonary function
of fat & reduce salt intake. blood at a volume required to meet the body’s -Assess ECG for dysrhythmia due to Digoxin
-Stop smoking needs. toxicity and electrolyte imbalance.
-Do simple, regular exercise 20-30 mins a day -Assess respiration pattern & rate for
-Explain the medication’ Classification (based on symptoms & pt’s effort) pulmonary congestion
-Reduce anxiety by deep breathing. Class I Normal daily activity does not -Give oxygen if dyspnea
-Avoid sex for a few weeks. Consult the doctor. initiate symptoms. -Administer diuretic or vasodilator to reduce
 Cardiac rehabilitation Class II Normal daily activity initiate preload and afterload
Phase I (admission till discharge)-inapatient symptoms, bit subside with rest. -Serve Morphine to decrease anxiety
Self care, exercise, diet, smoking Class III Minimal activity initiate symptoms. -Assist in intubation & mechanical
Phase II (After discharge and last for 4-8 weeks) No symptoms at rest. Ventilation
Level of activity, psychological, modify risk Class IV Any activity initiates symptoms -Daily weight in fluid management.
factors, and return to work. and also present at rest.
Phase III (Maintenance)- Follow-up.
 Promote comfort and emotional support Clinical Manifestation: Tricuspid Valve Regurgitation
-Restrict activity and assist ADL during SOB Dyspnea Fatigue
-Put patient on bed rest Palpitation Orthopnea Definition:
-Prop up the bed for maximal lung expansion Paroxysmal nocturnal Pulmonary venous Backflow of blood from right ventricle into right
-Document signs of activity intolerance such dyspnea hypertension atrium during systole.
as dysnea, fatigue & tachycardia.
 Monitor effects of pharmacological therapy Diagnostic test: Diagnostic test:
-Know the action, side effect & toxic level I. Chest X-ray: Left atrial enlargement and I. ECG: Incomplete right BBB
-Monitor hemodynamic status closely cardiomegaly II. Chest X-ray: Cardiomegaly
-Document correctly intake & output II. ECHO III. ECHO: Identify the presence & severity
 Provide adequate nutritional intake
-Monitor closely for nausea & low appetite Treatment Treatment:
-Encourage small, frequent meal Acute Chronic  Tricuspid valve annuloplasty
-Advice family members to provide tasty food  IV Nitropruside to  Medication to delay  Tricuspid valve replacement.
from home which compatible with condition. reduce afterload surgery or
 Provide patient education  IV Nitroglycerin to preventing left Pulmonic Valve Disease
-Assess understanding of the disease & risk reduce pulmonary ventricular
factors of heart failure. pressures dysfunction Definition:
-Educate the importance of diet restriction  Assess ventricular Stenosis- Narrowing of the pulmonic valve orifice
 IABP to stabilize
-Educate importance of daily weight, fluid size, function & Regurgitation- Backflow of blood from pulmonary
vital signs
restriction & medication to control symptom severity every 6-12 artery into the right ventricle
 Mitral valve repair/
-Educate importance of lifestyle changes like replacement month by ECHO.
smoking, weight loss & exercise Diagnostic test:
-Inform when to call or seek treatment I. ECG: Incomplete right BBB
Aortic Valve Stenosis
II. Chest X-ray: Prominent pulmonary artery
VALVULAR HEART DISEASE III. ECHO: Identify right ventricular hypertrophy
Definition:
IV. Catheterization: Comfirm the diagnosis
Narrowing of aortic valve orifice which impedes
Definition: the blood flow from heart to body.
Several disorders and diseases of the heart CARDIOMYOPATHY
valves, which are the tissue flaps that regulate Diagnostic test:
the flow of blood through the chambers of the Definition:
I. ECG: Abnormal pattern reflecting thickening
heart. A disease of heart muscle & associated with
of heart muscle
ventricular dysfunction.
II. Chest X-ray: Dilation of aorta above the valve
Mitral Valve Stenosis III. ECHO: Diagnose & evaluate the severity
Hypertropic Obstructive Cardiomyopathy
Definition: Treatment:
2
Narrowing of mitral valve orifice (<2cm ). The Definition:
 Restriction from activity
thickened, calcified valve cannot open or close Excessive myocardial hypertrophy which the
 6-12 month evaluation by ECHO to indicate
passively, obstructing flow of blood from left heart able to contract but unable to relax and
aortic valve replacement.
atrium to left ventricle. remain stiff in diastole.
 Antibiotic prophylaxis given to avoid
endocarditis.
Clinical Manifestation Clinical manifestation:
 Diuretics
Dyspnea Fatigue Supraventricular Ventricular
Chest pain Atrial Fibrillation tachycardia (SVT) Tachycardia (VT)
Aortic Valve Regurgitation
Syncope Shortness of breath
Diagnostic test: Fatigue Atrial Fibrillation
Definition:
I. Chest X-ray: Pulmonary congestion, Backflow of blood into the left ventricle during
enlargement of main arteries & Lt atrium. ventricular diastole. Diagnostic test:
II. ECG: Atrial fibrillation 1. Physical examination
III. ECHO: Valve leaflet thickening & restricted Treatment: 2. Chest X-ray
opening 3. ECHO
 Aortic valve replacement
IV. Cardiac catheterization 4. Genetic testing
Tricuspid Valve Stenosis
Treatment: Treatment:
 Diuretics & sodium restriction Definition:  Beta blockers to reduce heart rate
 Anti-arrhythmia to treat atrial fibrillation Narrowing of the tricuspid valve orifice results in  Anti-arrhythmia
 Anticoagulant to prevent thromboembolism increase pressure in right ventricle.  Anti-coagulant
 Beta blockers/CCB/digoxin to control HR  Activity restriction to reduce sudden death
 Antibiotic for prophylaxis of rheumatic fever Diagnostic test:  Implantable cardioverter defibrillator
 Percutaneous Balloon Vulvotomy I. ECG: Tall P wave in sinus rhythm  Myectomy to improve blood flow from heart.
 Mitral commissurotomy II. ECHO: To identify the presence & severity.
 Mitral valve replacement Dilated Cardiomyopathy
Treatment:
Mitral Valve Regurgitation  Sodium restriction Definition:
 Diuretics Characterized as dilation of both ventricles
Definition:  Tricuspid Valve Replacement without muscle hypertrophy.
Backflow of blood in left atrium with each
ventricular contraction due to rupture of chordae Types:
tendinae/ papillary muscle (emergency) or Ischemic Repeated MI/ myocardial injury
dilatation of left atrium to maintain CO. Familial Idiopathic /genetic
Clinical Manifestation: Monitoring: ELECTROCARDIOGRAM (ECG)
Low cardiac output Dyspnea Non invasive Invasive
Fatigue Orthopnea Consciousness level CO- Arterial line/ CVP 12 lead ECG consist of:
Liver enlargement Syncope Vital signs Ventilator a) 6 limb leads (I, II, III, aVR, aVL, aVF)
Oxygenation Urine output b) 6 chest leads (V1-V6)
Restrictive Cardiomyopathy Infection signs Arterial Blood Gases c) Standard speed of 25mm/second
Urine output Blood results d) Small box = 0.04 sec = 1 mm
Definition: Skin turgor ECHO/ TOE e) Large box = 0.20 sec = 5 mm
Characterized as ventricular wall rigidity due to Peripheral perfusion
myocardium scarring.
Treatment:
Clinical manifestation:  Restoring blood volume and ensure
Shortness of Breath Edema oxygenation and blood pressure adequate.
Palpitation Disrhythmia -Normal Saline
-Hartmann Solution Crystalloids
Diagnostic test: -Dextrose solution
+ Physical examination -Albumin
+ ECG -Polygeline
-Gelatin Colloids
+ ECHO
+ MRI -Hetastarch
-Blood products
Treatment:  Airway managed & initiate oxygen therapy
P wave Atrial contraction 0.08-0.10 sec
 Diuretics  Vasopressant to induce vasoconstriction
QRS Ventricular 0.06-0.10 sec
 ACE inhibitor  Use anti-shock trousers to concentrate blood complex contraction
 Exercise restriction in vital organs (lungs, brain, heart)
T wave Ventricular relax -
 Keep patient warm
PR AV node function 0.12-0.20 sec
SHOCK  Antibiotics to prevent sepsis interval
 Adrenaline to stimulate cardiac performance
Definition:  Corticosteroid to reduce inflammation ST segment
A serious, life threatening medical condition  Trendelenburg position to shunt blood back  Measured from end of QRS complex to
where there is insufficient blood flow to meet to body’s core beginning of T wave.
tissues demand.  Chest tube to treat pneumo/hemothorax  Evaluate base on shape & location
 Thrombolysis to reduce size of clot.  Normally flat/isoelectric level
Stages of shock  Pericardiocentesis to treat tamponade
Initial 1 mm above Myocardial ischemia
CARDIAC TAMPONADE 2 mm above Myocardial infarction/
•Hyperperfusion causes hypoxia. pericarditis
•Cellsperform anaerobic respiration leading Definition: 1 mm below Myocardial ischemia
to lactate & pyruvate build up causing Sudden accumulation of blood, fluid, clots, pus or
metabolic acidosis. gas in pericardial space resulting in compression QT interval
Compensatory of heart muscle & interfere systole & diastole.  Indicates total time from onset of contraction
to relaxation.
•Hyerventilate to clear CO2 and improve pH. Clinical Manifestation:  Shorten with fast HR, lengthen in slow HR
•Baroreceptors detect hypotension due to Tachycardia Difficulty in breathing  Normal: <46 sec (women), <0.45 sec (male)
vasodilatation Hypotension Jugular vein distension  Prolong indicates torsades de pointes,
•Adrenaline is released to increase BP. Shock Oliguria electrolyte imbalance, dysrhythmic treatment
•Renin-angitensin axis is activated and Restlessness Dyspnea
vasopresssin released to conserve fluid via Reading ECG
kidneys reducing urine output. Risk Factors: 1. P wave presence and have relation with QRS.
•Vessels in other organ also constrict to  Blunt/ penetrating cardiac trauma 2. PR interval duration
divert blood to heart, lungs & kidneys.  Post cardiac catheterization 3. QRS complex shape, width & duration
 Anticoagulant therapy 4. QT segment length
Progressive (decompensating)
 Myocardial Infarction 5. ST segment elevation.
•Vessel constriction causes blood remain in  Acute pericarditis
capillaries. Methods in calculating heart rate
•Hydrostatic pressure increase and Management: i. No. of R-R intervals in 6 sec times 10
histamine released cause leakage of fluid  Pericardiocentesis (Irregular rhythm)
and protein into surrounding tissue. -Aspirate fluid from pericardial by needle ii. No. of large boxes between QRS complex
•Blood concentration increase causing  Subxiphoid pericardiostomy divided into 300
sludging of microcirculation. -Drain pericardial sac iii. No. of small boxes between QRS complex
•Vital organ compromised due to reduced  Emergency thoracotomy divided into 1500
perfusion. -Pericardial sac evacuation
 Fluid resuscitation *If HR>200 bpm or <30 bpm, emergency
Refractory
-Blood products, colloids, crystalloids measures are taken.
•Vital organ failed and brain death occured.  Inotropic agent
•Death will occur imminently. -Increase myocardial contractility and CO
 Airway
-Oxygen, intubation, mechanical ventilation
HEMODYNAMIC MONITORING
Definition:
Is the bedside measurement of the ever-changing
pressure of blood flow through the cardiac,
pulmonary & systemic vasculature via invasive
catheters.
Benefits:
 Improve patient outcome
 Lower mortality rates
 Better quality of life after critical illness
Measurement:
Direct Indirect (calculation)
 CVP  Cardiac output
 Rt Ventricle Pressure  Cardiac Index
 Pulmonary Artery P.  Lt Ventricular
Ejection Fraction
 Lt Atrial Pressure
 Capillary Wedge P.
Tools:
Intra-Arterial Purpose
Catheters (IAC)  Measure MAP correctly
 Draw blood for ABG
 Monitor Arterial BP
Insertion site
* Radial artery
* Femoral artery
* Dorsalis pedis
* Brachial artery
* Axillary artery
Central Venous Purpose
Access  When peripheral site
nor accessible
Insertion site  For fluid resuscitation
* Subclavian vein  CVP monitoring
* Brachial vein  Access for PAC
Jugular vein  Monitor blood
circulation
Pulmonary Artery Purpose
Catheter (PAC)  Measure pressure in
both side of heart &
Insertion site pulmonary artery
* Subclavian vein  Measure CO
* Jugular vein  Blood for mixed venous
* Femoral vein  Fluid infusion
* Brachial vein
Nursing intervention
th
 Tranducer at 4 ICS
 Zero transducer b4
read
 Supine/ Semi-fowlers
Intra-aortic Purpose
Balloon Pump  Support in low CO & BP
(IABP)  Post CABG
Insertion site Signs of complications
* Femoral artery  ↓ Peripheral pulses
 ↓ Urine output
 Balloon migration
 ↑ temperature/ WBC
 ↓ Hematocrit (bleed)
Weaning:
 Hemodynamic stable
 No chest pain
 Adequate urine output
ACUTE LUNG INJURY (ALI) PNEUMONIA
Definition: Definition:
A systemic process of pulmonary manifestation Acute inflammation of the lung parenchyma
which cause multiple organ dysfunction
syndromes. Severe ALI is known as Acute Community Acquired Hospital Acquired
Respiratory Distress Syndrome (ARDS). Pneumonia (CAP) Penumonia (HAP)
Pathogens Pathogens
Clinical Manifestation: -Strep. Pneumoniae -Staph. Aureus
Exudative phase Fibroproliferative -Legionella sp. -Strep. Pneumoniae
phase -H. Influenzae -Pseudomonas
* Tachypnea * Agitation -Staph. Aureus -Aceno. Baumannii
* Restlessness * Dyspnea -Mycoplasma pneu. -Klesiella sp.
* Anxiety * Fatigue -Clamydia pneu. -Proteus sp.
* Use accessory * Use accessory -Pseudomonas -Serratia sp.
muscles muscle excessively Risk factors Risk factors
* Fine crackles Alcoholism Elderly
COPD COPD
Risk factors: Diabetes Chronic illness
Direct Indirect Malignancy Mecha. ventilation
 Aspiration  Sepsis Coronary disease Smoking
 Drowning  Trauma
 Toxic inhalation  Hypertransfusion Clinical manifestation:
 Pulmonary  CABG Dyspnea Uremia
contusion  Severe pancreatitis Fever Thrombocytopenia
 Pneumonia  Embolism Cough Hypoxemia
 Oxygen toxicity  Shock Coarse crackles Tachypnea
Pathophysiology Diagnostic test
a. Chest X-ray
After direct/ indirect injury, inflammatory-
b. Sputum culture
immune system is stimulated
c. Bronchoscopy
Inflammatory mediators released from the d. Full Blood Count
site e. Arterial Blood Gases
Causes neutrophils, macrophages & platelet Nursing management:
accumulate in pulmonary artery. i. Optimize oxygenation & ventilation
-Oxygen therapy
Initiate humoral mediators that damage
-Positioning
alveolar-capillary mambrane.
-Secretion clearance
Alveolar collapse and cause increase work of -Bronchodilators
breathing ii. Prevent infection spreading
-Proper hand washing
-Administer antibiotic
Hypoxemia
iii. Provide comfort & emotional support
-Adequate rest
Diagnostic test: -Perform procedures as needed
I. Arterial Blood Gases (ABG) -Explanation on procedures
-↓ PaCO2: Despite high oxygen demand iv. Prevent complications
-↑ PaCO2: Hyperventilation, fatigue -Close monitoring
-↓ pH: Respiratory acidosis -Aseptic technique
II. Chest X-ray
PULMONARY EMBOLISM
Management:
Medical Nursing Definition:
Mecha. Ventilation  Optimizing Occurs when thrombotic embolus (clots) or non-
 Low tidal volume oxygenation & embolus (fat, air, foreign bodies) stuck into the
(6ml/kg)- prevent ventilation pulmonary arterial system, disrupting blood flow
Barotrauma  Preventing to the lungs.
Pemissive desaturation Pathophysiology
hypercapnia  Promote When occluded, alveolar dead space ↑
 Increase CO2 secretion
slowly clearance ↑ work of breathing
Oxygen therapy  Positioning
Tissue perfusion  Provide comfort & Hypercapnia & hypoxia causes
 Adequate CO emotional support bronchoconstriction
 ↑ contractility  Prevent
complications ↑ pulmonary vascular resistance
 Restrict fluid
 Diuretics ↑ right ventricular workload
Clinical manifestation: BASIC AIRWAY MANAGEMENT MECHANICAL VENTILATION
Tachycardia Hemoptysis
Tachypnea Cough Oxygen administration: Definition:
Dyspnea Crackles Types Amount/percentage A mode of assisted or controlled ventilation using
Anxiety Fever Nasal cannula 2-6 Lpm/25-50% mechanical devices that cycle automatically to
Face mask 6-10 Lpm/ 35-60% generate airway pressure.
Risk factors: Partial rebreather >10 Lpm/ >60%
Venous stasis (AF,↓ CO, immobility) Non rebreather >10Lpm/ 60-95% Types:
Injury to vessels (infection, incision) Demand valve 100 Lpm/ 100% i. Volume-cycled: Preset tidal volume
Polycythemia Venturi mask With reservoir 50% ii. Pressure-cycled: Preset pressure limit
Cardivascular disease (HF, cardiomyopathy) (15 Lpm) No reservoir >95% iii. Flow-cycled: Preset flow rate
Cancer iv. Time-cycled: Preset time factor
Trauma Intubation
Pregnancy  Techniques Modes:
 Head tilt, chin lift: Tongue may obstruct
Diagnostic test:  Jaw thrust: For spinal injury patient Control Ventilation (CV)
 Arterial Blood Gases (↓ PaCO2, ↓PaO2, ↑ pH)  Body position
 ECG (sinus tachycardia, BBB, AF) •Deliver preset volume/pressure despite own
 Lateral position allow fluid drain out inspiratory effort
 Chest X-ray (cardiomegaly, pleural effusion)  Used when no spinal injury
 Pulmonary angiogram •Used for apneic patient
 If so, patient secured on a board first.
 DVT studies
 Airway adjunct Assist-Control Ventilation (ACV)
 Oropharyngeal:
Management:
-For unconscious patient •Deliver breath in response to own effort &
Medical Nursing
-Measure from mouth to angle of when fail to breathe.
~ Fibrinolytic agents ~ Optimize ventilation
mandible •Used in spontaneous breathing with weaken
(streptokinase) & oxygenation
 Nasopharygeal: respiratory muscle
~ Embolectomy ~ Monitor bleeding
-For conscious patient Synchronize Intermitten Mandatory
~ Anticoagulant ~ Provide comfort
-When oropharungeal airway not Ventilation (SIMV)
(heparin or warfarin) ~ Prevent
accessible
~ Inotropes complications •Ventilator breath are synchronize with own
-Measure from tip of nose to end of
~ Fluid ~ Health education effort
earlobe
 Laryngeal mask: •Used in weaning from ventilation
PNEUMOTHORAX
-For unconscious patient
Pressure Support Ventilation (PSV)
-Not suitable if esophagus is injured
Definition:
-Must be remove after patient conscious
Accumulation of air between the parietal & •Preset pressure that augment own
-Does not prevent aspiration inspiratory effort & decrease work of
visceral pleura with lung collapse.
 Tracheostomy: breathing
-For prolong ventilation •Used in weaning with SIMV mode
Types:
-When patient fail to be intubated
Spontaneous -Done in OT Positive End Expiratory Pressure (PEEP)
•A closed pneumothorax (no leak)
•Causes: Rupture of visceral layer due to Complications of intubation:
infection (primary), disease complication  Laceration of gum, lip, vocal cord, pharynx •Used with CV, AC & SIMV to improve
(secondary)  Broken teeth oxygenation by opening collapse alveoli.
•Symptoms happen during rest  Vocal cord paralysis
 Pneumothorax Constant Positive Airway Pressure (CPAP)
Traumatic
 Esophageal intubation
•Can be opened (opening in chest wall) or  ETT dislodgement •Similar to PEEP but used only with
closed spontaneously breathing patient.
•Causes: Penetrating injury (biopsy, Suctioning: •Maintain constant +ve pressure in airways.
thoracocentesis), fracture, PEEP, CPR  Hyperventilate patient or apply high-
Independent Lung Ventilation (ILV)
Tension concentration of oxygen before suction
 Use sterile apparatus
•Air enter pleura space when inhale and •Ventilate each lung separately. Requires 2
 Maximum of 10 sec on each suction ventilator and sedation.
cannot escape because of flap-valve effect.
 Be gentle
Life- threatening (↓ CO) •Used in unilateral lung disease/ different
 Rotate the catheter when withdrawing it. disease process in each lung
•Causes: Trauma, infection, mechanical
 Apply aseptic technique
ventilation
 Use soft, flexible catheters High Frequency Ventilation (HFV)
 Monitor for arrhythmia
Management:
 Attach oxygen after suction •Deliver small gas amount at rapid rate (60-
1. Oxygen therapy
100 bpm). Require sedation
2. Analgesics
•Used in hemodynamic instability, in short-
3. Thoracocentesis
term procedure or risk of pneumothorax.
4. Chest tube
5. Thoracotomy- prevent recurrent Inverse Ratio Ventilation (IRV)

•I:E ratio reversed to allow longer inspiration.

Require sedation.
•Improve oxygenation in hypoxic patient with
PEEP. Keeps alveoli from collapse.
 Settings: Physiological NON INVASIVE VENTILATION
Ventilator Modes used in delivering A. Respiratory
Modes positive pressure. -Barotrauma Definition:
Respiratory Number of breath ventilator -Atelectasis Delivery of mechanical ventilation with a nasal or
Rate delivers per minute -Infection (VAP) face mask.
(10-12/min) B. Cardiovascular
Tidal Volume delivered to patient -Decrease venous return and CO Advantages:
Volume during normal ventilator C. Gastrointestinal  Prevent intubation
breath (7-10 ml/kg). Volume -Gastric ulceration  Enhance alveolar ventilation
>10 ml/kg cause volutrauma. -Microaspiration  ↓ work of breathing
Inspiratory A measure of preset D. Renal/ hepatic  Improve gaseous exchange
flow respiratory volume: the more -Decrease urine output  ↓ nosocomial infection
quantity of a flow, the more -Sodium & water retention  Enhance patient comfort
quickly ventilator will submit -Decrease portal blood flow  ↓ length of stay
mandatory respiratory volume E. Central Nervous System  ↓ cost
(45-60 L/min) -Decrease cerebral perfusion following
excessive PEEP Indication
I:E ratio Ratio comparing time
 AECOPD & respiratory failure
delivering O2 and time to
Drugs used in managing ventilated patient:  Respiratory failure with hypercapnia
exhale (1:2).
a) Sedative/ analgesics  Respiratory failure with acute hypoxemia
PEEP Positive pressure applied at
-Midazolam  Asthma
end of expiration (3-5 cm H2O)
FiO2 Select delivery of O2 (21- -Morphine
-Propofol Methods:
100%). Should be the lowest 1. Continuous Positive Airway Pressure (CPAP)
level to prevent oxygen b) Neuromuscular Blocking Agent (NMBA)
-Suxamethonium o Air delivered via mask fit to patient’s face
toxicity. o Pump provide positive pressure
-Vecuronium
Inspiratory A control that adjust ventilator o Increase amount of air breathed in
-Atracurium
trigger response to patient o Not increase work of breathing
respiratory. o Patient breathe spontaneously
Care of Patient on Mechanical Ventilator
 Check ventilator settings according to doctor’s o Usual range 5-15 cmH20
Criteria for starting mechanical ventilation: 2. Bilevel Positive Airway Pressure (BiPAP)
order every shift
i. Respiratory rate >35 or <5 breaths/minute o Provide higher positive pressure for
 Make sure alarm are set
ii. Hypoxia: central cyanosis inspiration
 Empty ventilator tubing when moisture collects.
iii. Hypercapnia o Enhance oxygenation & ventilation
Never empty the fluid back into the cascade
iv. Decreasing conscious level o Higher pressure is for inhalation (IPAP),
 Ensure temperature of delivered air maintained
v. Significant chest trauma lower pressure for expiration (EPAP)
at body temperature
vi. Tidal volume <5ml/kg o When inhale, air flow in high pressure to
 If on PEEP, observe peak airway pressure to
vii. Control ICP in head injury support inhalation.
determine the proper level
viii. Following cardiac arrest o Increase delivery of air with less breathing
 Assess patient’s respiratory status every shift:
ix. Prolong major surgery workload.
 Take vital signs 4 hourly
 Check cuff pressure everyday to ensure tidal
Definition of weaning: Nursing management
volume
Gradual withdrawal of the mechanical ventilator Claustrophobia Assess for comfort
 Provide mouth care every 2-4 hours
& reestablishment of spontaneous breathing Serve anxiolytic
 Observe the need for suction every 2 hours
 Provide tracheostomy care every shift. Pressure on Place hydrocolloid dressing
Criteria for weaning: face
 Change tube tape as needed
a. Respiratory rate <25 per min Mucosal Apply lip balm or nasal
 Check mouth for pressure sores.
b. Tidal volume 3-5 ml/kg dryness spray
 Move the tube to opposite side of mouth every
c. pH >7.35 Stomach Insert nasogastric tube
24 hour to prevent ulcers
d. PaO2 >80 mmHg with FiO2 <0.5 distension
 Maintain accurate intake & output records
e. PaCO2 35-45 mmHg Aspiration Check for nausea, abdo
 Position patient every 2 hours to prevent
complication of immobility girth
Factors to consider before weaning Serve antiemetic
 Plan nursing care to provide rest
-Resolution of underlying pathologic condition Corneal Ensure mask fit well
 Include patient & family members in care
-Chest X-ray show good lung expansion irritation Apply eye drop
 Provide materials for communication
-Acceptable ABG with ventilator support Hypoventilate Ensure mask fit well
 Observe for gastrointestinal distress
-Sepsis under control
 Administer medication as appropriate
-Awake with intact respiratory drive
 Initiate relaxation technique
-Minimal inotropic support ARTERIAL BLOOD GASES (ABG)
 Monitor for complication (barotraumas, ↓ CO)
-Good hydration with normal serum electrolyte
 Monitor readiness to wean.
-Adequate nutrition & energy Interpreting ABG
-Intact gag & cough reflex before extubation 1. Partial pressure of Oxygen (PaO2)
2. pH level
Complications: 3. Partial pressure of Carbon Dioxide (PaCO2)
Mechanical- Equipment malfunction 4. Bicarbonate (HCO3)
a) Ventilator
Fail to cycle, Power failure
b) Circuit
Disconnection, Infection
c) Humidifier
Inadequate humidification, overheating
 Estimation of burn size DIABETIC KETOACIDOSIS (DKA)
Disorder pH PaCO2 HCO3 I. Rule of nine
mmHg mEq/L Divides body part into 9% of TBSA each Definition:
Respiratory acidosis II. Lund & Browder chart A metabolic state resulting from a profound lack
Uncompensated < 7.35 > 45 normal Surface area is based on age of insulin, usually found in type I DM. Inability to
Partially < 7.35 > 45 > 26 III. Palmar method inhibit glucose production from the liver results
Compensated normal > 45 > 26 Use patient own hand, representing 11% of in hyperglycemia, which can be extreme and lead
Respiratory alkalosis TBSA to severe dehydration.
Uncompensated > 7.45 < 35 normal
Partially > 7.45 < 35 < 22 Degree of burns Pathophysiology
st
Compensated normal < 35 < 22 1 degree -Superficial burn Hyperglycemia (absolute deficit in
Metabolic acidosis -Causes pain, redness, swelling insulin)
Uncompensated < 7.35 normal < 22 -Heal within 3-5 days
nd
Partially < 7.35 < 35 < 22 2 degree -Partial thickness burn Inability of glucose to move into cells,
Compensated normal < 35 < 22 -Causes pain, swelling, blister increasing its level
Metabolic alkalosis -Heal within 10-14 days
Uncompensated > 7.45 normal > 26 rd
3 degree -Full thickness burn Fat from adipose tissue converted into
Partially > 7.45 > 45 > 26 -Causes black,char skin, numb free fatty acids (FFA)
Compensated normal > 45 > 26 -Heal within 30 days-months
Mixed
Alkalosis < 7.35 > 45 < 22 FFA converted to
Diagnosis test: glucose by liver
Acidosis > 7.45 < 35 > 26  Arterial Blood Gases
 Carboxy Hb level
Causes:  Coagulation studies Liver also convert
Respiratory ~ Fever  Group Cross Match (GXM) glycogen into glucose
alkalosis ~ Trauma  Urine analysis
~ CNS infection Worsen the
~ High altitude Management: hyperglycemia
~ Pneumothorax a) Resuscitative phase
~ Pregnancy -Adult (> 15%), children (>10%) Clinical Manifestations:
Respiratory ~ Airway obstruction -Fluid resuscitation (Ringer’s Lactate): Hyperglycemia Coma
acidosis ~ Pulmonary edema Parkland’s Formula ↑ ketone level Shortness of breath
~ Pneumonia (4 x BSA involved x body weight) Polydipsia Weakness
st
~ CNS depression -50% given in 1 8 hours, 50% nest 16 hours Polyuria Weight loss
~ Neuromuscular impairment b) Acute phase Polyphagia Abdominal pain
Metabolic ~ Volume depletion -Wound care Nausea & vomiting Dehydration
alkalosis ~ Bicarb administration -Open dressing: Apply topical agent with gauze
~ Diuretics -Close dressing: Use gauze to cover after apply Complication:
Metabolic ~ Diarrhea topical agents 1) Cerebral edema
acidosis ~ Renal insufficiency -Apply topical antimicrobial (Silver nitrate) -Brain swell due to water accumulation
~ Rapid saline administration c) Rehabilitation phase 2) Acute kidney failure
~ Starvation -Physiotherapy -Caused by severe dehydration
~ DKA -Psychiatry 3) Acute Respiratory Distress Syndrome
~ Lactic acidosis -Social worker -Lungs filled with fluid causing SOB
4) Hypoglycemia
BURNS Nursing care: -Insulin enter into cells and ↓ glucose level
 Strict intake & output chart 5) Hypokalemia
Definition:  Vital signs monitoring -Due to fluid & insulin used in treating DKA
Tissue damage caused by such agents as heat,  Pain assessment, administer analgesics
chemicals, electricity, UV light or nuclear  Nutrition (high protein, enteral feeding) HYPERGLYCEMIA HYPEROSMOLAR NON-
radiation. Leading cause of death is infection. KETOACIDOSIS SYNDROME (HHNS)

Types Causes Definition:

Thermal Hot water, flammable liquid, Hyperosmolarity & severe hyperglycemia
explosion, fire predominate with change of mental status due to
Electrical Massive electrical current insulin resistance. Occurs in type II DM.
Chemical Strong acid/ alkali, mustard gas
Radiation Exposure to UV light Pathophysiology

Classification of burn Deficit in insulin prevent glucose enter cells

Major  25% of TBSA
 10% of TBSA full-thickness burn Glucose level ↑ & blood become
 Deep burn (head, perineum) hyperosmolar
 Inhalational injury
 Chemical/high voltage burn Fluid drawn from the cell into vascular bed
Moderate  15-25% of TBSA Body try to eliminate excessive glucose by
 Superficial partial thickness burn urinating
(head, perineum, limbs)
 Suspected child abuse If patient do not consume enough water, it
 Concomitant trauma may results in severe dehydration
Minor  15% of TBSA
Clinical manifestations: Brain * Hyperventilate TRAUMA CARE IN EMERGENCY
Hyperglycemia Polyuria herniation * Mannitol
Dehydration Weakness * Immediate CT brain Triaging
Excessive thirst Weight loss * Contact neurosurgeon  Categorising the patient according to
Confusion Fatigue Thoracic * Adequate pain control treatment priority.
trauma * Adequate oxygenation  A 24 hour basis by well trained Triage
Risk factors: * Chest wall stabilization Officers.
A. Poor DM control * Treat complication  Triage criteria:
B. Non compliant to DM treatment Pneumothorax * Chest tube insertion Non-critical Walk-in & stable
C. Drink inadequate water * Needle thoracostomy Semi-critical Hemodynamically stable
D. Intravenous feeding- ↑ glucose * High flow oxygen but unable to walk
E. Peritoneal dialysis * Asherman chest seal Critical Critically ill, require
F. Diuretics Massive * Tube thoracostomy immediate treatment.
hemothorax drainage
Complication: * Thoracotomy Zone & facilities:
1) Shock * Adequate fluid volume Resuscitation  Resuscitation bays
2) Coma Cardiac * Pericardiocentesis zone -Emergency treatment
3) Acute tubular necrosis temponade “golden hour”
4) Vascular thrombosis Aortic rupture * Maintain adequate volume -Activation of trauma team
5) Death * Angiogram  Critical care bays
* Emergency endovascular -Observation & monitoring
Management for DKA and HHNS: stent graph Immediate  Immediate bays
Medical Nursing Renal injury * CRIB Care zone -Active bays for incoming
* Fluid resuscitation * Administer fluid, * Sedation semicritical
* Administer insulin insulin, electrolyte * Observation (abd, girth)  Observation bays
* Restore electrolyte * Monitor compliant * IV fluid (major injury) -Observation for semi-
* Patent airway to therapy * Antibiotic critical cases
* Enough ventilation * Prevent * Full laparotomy
 -Duration stay <12 hours
& oxygenation complications GI injury * Debride devitalized tissue
Green zone Consultation room
* Close monitoring * Patient education * Anastomoses if required
-Minor treatment prior to be
* NGT suction
discharge
Patient education for DKA & HHNS: * IV fluids
 -Eg: injection, dressing
a. Control blood sugar Pancreatic * External drainage
Asthma bay  No waiting time
b. Consult doctor for blood sugar level target injury * Control hemorrhage
Liver injury * Close monitoring  Emergency treatment
c. Drink a lot of water
* Blood transfusion One Stop Victims of domestic violence,
d. Take medication as ordered
* Laparotomy Crisis Centre rape, child abuse
e. Watch for signs & symptoms- Ketone in urine
Spleen injury * Close monitoring (OSCC)  Registration done in the
* Assess for bleeding room by emergency staff
Comparison between DKA & HHNS
DKA HHNS * Splenectomy
Vertical Shear * Apply compression belt/ Stabilization & transport of critically ill patient:
In type I DM In type II DM
external fixator Indication Contraindication
Sudden onset Slow onset
* Peritoneal aspiration  Diagnostic purpose  Increase potential
↑ ketone level Normal level * Urine catheterization  Therapeutic risk
Serum sodium low Serum sodium high * Suprapubic cystotomy purpose (surgery)  Unstable/potential
Low bicarb level Normal level * Bed rest  Specialized care patient
Urine ketone present No urine ketone Acetabular * Traction (ED to ICU)
fracture * Reduce dislocation
POLYTRAUMA * Operative reduction (if fail) Potential mishap:
Pelvic fracture * Massive fluid replacement Accidental extubation
Definition: * Immobilization Ventilator disconnect
Consecutive systemic reactions which may lead * Bleeding control ECG disconnect
to dysfunction or failure of remote organs and Fat embolism * Adequate oxygenation Monitor power failure
vital systems. * Stabilizing hemodynamic Vaso-active drug interruption
* DVT prophylaxis IV infiltration or disconnection
Trauma death: Second death peak occurs within * Early immobilization
minutes to several hours after injury. This period * Use corticosteroid & Elements:
is called “Golden Hour” characterized by: heparin reduce APO i. Communication
-Rapid transportation Hypothermia * Cover with warm blanket - Reason for transport
-Rapid assessment& stabilization * Warm IV fluid before infuse -Patient’s condition
-Rapid definitive care Shock * Oxygenation -Equipment needed
* Arrest bleeding -Notify receiving department before transfer
Conditions & its management: * Pneumatic antishock
Head injury * Airway, breathing, garment
circulation * Monitor vital signs, I/O,
* Neurological assessment; CVP, acid-base balance
GCS * Blood tranfusion
Obtain CT brain if comatose,
unequal pupils, GCS <13/15
 ii. Equipments Muscle relaxant/paralytics
-Small size, light Indication  For intubation
-Compatible  In mechanical
-Safe to staff and patient ventilation
Monitors -Know how to operate  Prevent increase in ICP
-Monitors ECG, ABP, ICP,  Reduce lactic acidosis
SpO2, capnograph Common drugs
Ventilators -Different modes Depolarizing Eg: Succinylcholine
-High & low pressure alarms agents
-Electrically powered Non- Eg: Pancuronium,
-Have humidification system depolarizing Vecuronium, Atracurium
-Oxygen supply, backup
Medication -List of drugs to be used Vasopressors
& infusion -Aware of drug effects Indication  Increase contraction (β1)
-Use plastic infusion bag  Vasodilate vessels (β2)
-Test IV drip before infuse  Bronchodilate (β2)
iii. Monitoring  Vasoconstrict (α)
-Pulse, SpO2, BP, RR Common drugs
iv. Handling over (documentation) Dopamine + Increase mesenteric blood
-Indication for transport flow
-Patient status during transport + Risk of tachyarrhythmias
(Vital signs, level of consciousness) Dobutamine + Primarily β1
+ SVR may decrease
COMMON DRUGS IN ICU + Useful in Rt heart failure
+ Risk of tachyarrhythmias
Sedation Isoproteronol + Positive chronotrope
Indication Relieve pain + Increase HR & myocardial
Reduce anxiety & oxygen consumption
agitation + May worse ischemia
Provide amnesia PDE inhibitor
Reduce patient-ventilator * Milrinone + Positive inotrope &
dysynchrony * Amrinone vasodilator
Reduce respiratory + Little effect in HR
muscle oxygen + Used in CHF
consumption + Risk of tachyarrhythmia
Common drugs Adrenaline + Very potent agent
BDZ + No analgesic properties + Effect on metabolic rate
* Diazepam + Lipid soluble + Useful in anaphylaxis
* Lorazepam + Interact with propranolol + Risk of coronary ischemia,
* Midazolam renal vasoconstriction
Propofol + Respiratory & CVS Noradrenaline + Potent α agent
depression + Tend to spare brain & heart
+ Only in ventilated patient + Good in increasing SVR
Butyrophenones + Anti-psychotic tranquilizer + Can cause reflex
* Haloperidol + In agitated, delirious bradycardia
&psychotic patient Phenylephrine + Pure α agent
+ Patient can develop EPS + Cause minimal increase in
HR or contractility
Analgesics + Does not spare brain &
Indication  Relieve pain heart
Common drugs Ephedrine + Release tissue stores of
Opiods adrenaline
* Morphine + Morphine- hypotension + Last longer & less potent
* Fentanyl + Fentanyl- expensive than adrenaline
Non-opiods Vasopressin + Useful in septic shock
* Ketamine + Ketamine can cause + To parallel HRT
* Ketorolac nightmares, hallucination Nitroglycerine + Venodilator at low dose
& bronchodilate + Arteriodilation at high dose
+ Ketorolac side effect’s + Short duration, rapid onset
increase in critically ill & + Risk of ↑ ICP, headache
can cause renal failure. Nitroprusside + Balanced vasodilator
+ Rapid onset
+ Used in HPT emergency,
severe CHF, aortic
dissection
+ Risk of CN poisoning, ↑ ICP
Labetolol + α1 & β blocker
+ Does not ↑ ICP
+ Used in HPT emergency,
aortic dissection