Advanced Critical Care in Medical, Surgical & Neonatal Nursing SN Nanjunde Gowda, Jyothi Nanjunde Gowda
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1Management of Shock/Unconsciousness2

IntroductionChapter 1

Critically ill care and nursing has evolved over the last couple of decades into full pledge specialty. Critical care nursing requires not only knowledge and understanding of the human physiology, but also special procedure skills and wisdom to handle technology, knowledge and medical advances judiciously. The practice of critical care nursing is essentially team work and training, involves the health restoration functions for the individual patients and handling of the families and clients response to their illness in their hours of utmost need.
Critical Care Team
The critical care team includes a diverse group of highly trained professionals, who provide care in a specialized area known intensive care unit (ICU). This team works toward the best outcome possible for seriously ill patients. All members of the team may be asked to teach patients and their families various strategies to improve health, healing, coping and well-being, specific to their area of expertise. Members of the team include:
  • Physician
  • Surgeon
  • Specialist from internal medicine
  • Pediatrician
  • Anesthetist.
Critical Care Nurses
Critical care nurses provide a high level of skilled nursing for total patient care and often facilitate communication among all of the people involved in the care of patient. Their expertise and continuous presence allows early recognition of subtle, but significant changes in patient conditions, thereby preventing worsening conditions and minimizing complications that arise from critical illness or injury. Because of their close contact with the family and patient, critical care nurses often serve as the patient's advocate and become integral to the decision-making process of the patient, family and critical care team. Additionally, some critical care nurses are recognized as a critical care registered nurse (CCRN) (with special training). They have received more specialized education, training and testing and are certified by the authorized authority.4
Intensivists may be assigned to the ICU on a full-time basis and work with other critical care team members to provide their patients with ongoing and consistent care. It may also coordinate the administrative environment of the ICU by setting policies, developing protocols and facilitating communication among primary care physicians, specialists, patients and their families.
Dietitian is a vital part of the medical team that consults with physicians, nurses, therapists and family members in the ICU. The registered dietitian works to improve the nutritional health and promotes recovery of the critically ill or injured patient.
Social Worker
A social worker is a licensed professional that works with the ICU interdisciplinary team to provide a link between treatment plans for the critically ill or injured patient and family members. Special knowledge that is acquired through formal—professional and social work education, welfare policies and services, and social welfare systems and community resources guide the practice of social work.
Respiratory Therapist
Respiratory therapists work with the critical care team to monitor and assists with airway management of the critically ill patient. This may include oxygen therapy, mechanical ventilation management (breathing machine), aerosol medication therapy, cardiorespiratory monitoring, patient and caregiver education.
Physical Therapist or Occupational Therapist
The physical therapist provides services that restore function, improve mobility, relieve pain and prevent or limit permanent physical disabilities. The occupational therapist is trained to make a complete evaluation of the impact of disease on the activities of critically ill patient.
There are varieties of environment factors that affect patient on ICU or critical care area. They all interact with each other and can have significant effects on the health, well-being and outcome of critically ill patient. A lot of time, effort and money are invested in the technologies advances of critical care unit and also involvement of dedicated sympathetic multidisciplinary team.
Intensive care unit was developed as a consequence of the poliomyelitis epidemics of the 1950s, when extensive use of ventilation was required, 5since then the technology available to support the critically ill patient, has become more sophisticated and complex. Critical care unit consist of the following area:
  • Patient care area
  • Clinical support area consists of patient room and adjacent area
  • Unit support area, refer to areas of the unit where administrative, material management and staff function occurs
  • Family support area refer to area designed to support families and visitors
  • Design for an optimal functioning unit will consider the requirements of daily workflow.
Requirement of Critical Care Area
  1. Unit design begins with an in-depth analysis of patient care and support functions. An inventory of equipment and supply, both current and future, will help to determine space requirement. The design should reduce travel distance to staff, placing frequently needed space, equipment or material as close as possible to site of use.
  2. Care giver must be able to observe patient from many point within the unit.
  3. Many experts proposed units or patient room ranging from minimum of 6 beds to maximum of 8–12 beds, patient care area, single or multibed room and clear floor area, door and windows.
  4. Pleasant surrounding for patient, ward should include secure storage of patient and family clothing.
  5. The efficient unit is small enough for care providers to be fully aware of all activities on the unit.
  6. Electrical outlet need to be accessible from each side of the patient bed and arranged to provide enough room for multiple simultaneous procedures.
  7. The oxygen system must also be easy to access during intubation or extubation procedure.
  8. Each patient room may be equipped with television and educational entertainment system should be available.
  9. Medical gas vacuum.
  10. Supplies, in room storage and handling of patient care supplies must minimize on hand inventory and waste, while economizing efforts of bedside staff.
  11. Infection control is an important consideration and storage for clean and soiled items must prevent cross-contamination by visitors and staff.
  12. Specify the area location availability and usage for hand hygiene, toilets facilities and fluid disposal.
  13. For sharp object, container should be provided.6
  14. Emergency eyewash area will be used to address the issues.
  15. Nursing work station, clearly organized workplace for unit staff and patient care to improve communication. This area should include dedicated computer, telephone, paper, forms fax machine and digital technology within easy reach of staff.
  16. Preparing and dispensing patient medication: –
    • Medication delivery system may be automated
    • Medication should be easily accessible in life-threatening situation
    • Medication room should provide adequate space for medication storage.
  17. Storage location for electrical devices should provide adequate electrical outlet for charging.
  18. Hazardous waste, storage space for hazardous materials such as red bags and prompt removal of these materials should be planned.
  19. Emergency equipment and supplies and should be a sufficient space for storing emergency equipment, e.g. crash trolley life-support equipment.
  20. Within concurrence of the consultant microbiologist, infection control nurse and infection control team. Infection control precaution procedure should be agreed and enforced regarding:
    • Antibiotic policy
    • Clothing of staff and visitors
    • Aseptic precaution for invasive procedure
    • Use of disposable
    • Filtering of patient respired air
    • Changes of patient catheter, humidifier, ventilator and equipment
    • Cleaning of the unit
    • Isolation precaution.
  21. The limitation in communication, eating and movement all add to the stress experienced by the critical care patient.
  22. Patient has to rely on nurses to perform personnel hygiene, feeding and changing position in the bed, drug and equipment; patient should not feel they are not able to maintain privacy.
Ill Patient
Recognition that time is critical factor in determining whether an individual can survive trauma is old one. Baron Larry developed a system to expeditiously remove the wounded in Napoleon's armies from the war field more than 200 years ago. The concept used today in prehospital care is exactly the same as Larry's.7
In 1962, physician Deck Farrington JD (father of modern emergency medicine services) and Sam Banks instituted the first trauma course for ambulance. The course was started with Chicago Committee on trauma in Chicago Fire Academy with it. Farrington initiated the concept, now known as prehospital care and a true ambulance service.
The aims of prehospital care in critically ill patients include:
  • Rapid assessment
  • Appropriate airway management
  • Field control of hemorrhage
  • Stabilization of fractures and initiation of volume replacement enroute to hospital standard that the field time should be no longer than 10 minutes
  • Ambulance and the personal trained to provide initial resuscitation and triage are the elements of prehospital care.
Adams Cowley's statement is, you think people die from heart attacks or accidents, but they really do not directly. Those things produce shock, which is sluggish or non-existent circulation and that is what kills you. If you stay in shock for very long, you are dead. Maybe you will die in 10 minutes or maybe you will die next week, but you are dead, so if you are in shock, we have to work fast. You have at most 60 minutes. If I can get to you and stop your bleeding and restore your blood pressure, within an hour of your accident then I can probably save you. I call that the golden hour.
Phases of Prehospital Care
  • Development updating and approval of treatment protocols
  • Initial training and education of relevant personal
  • Purchasing, repairing and equipping of vehicles
  • Staffing of units, resupply of units.
Immediate Phase
  • Emergency medical service (EMS) access system
  • Observation of situation by emergency medical technician (EMT)
  • Assessment of patients and starting of treatment and physician at the hospital is notified of the situation, the number of patients their condition and the treatment that has been initiated.
Retrospective Phase
The retrospective component involves the development of continuing education program to bring new information to attention of the system's EMT. Continuing education in trauma care should include prehospital trauma life support of basic trauma life.8
Features of Prehospital Care
  • Extrication of causality and protection of cervical spine
  • Airway control
  • Control of hemorrhage
  • Venous access and intravenous (IV) fluids.
Treatment of Prehospital Care
  • Cardiac arrest
  • Cardiac tamponade
  • Tension pneumothorax
  • Evisceration of viscera
  • Splinting of fracture.
Administration of Drugs
  • Analgesics
  • Antibiotics
  • Tetanus prophylaxis.
All the features enumerated above firms, which is termed as advanced life support (ALS), when airway is supported by endotracheal intubation, circulation is supported by venous access and IV fluid administration.
Prehospital Care Protocols
Extrication Casualties and Protection of Spine
Extrication problems are acute in railway accident, house collapse and air disaster, although it does not pose much problem in road traffic accident. Cervical spine should be protected with rigid collar and patient is extricated and loaded on the stretcher in a single piece.
With airway begins the ABC of resuscitation, i.e. airway, breathing, circulation. Airway must be cleared of blood, mucus, vomit, foreign body or dentures. Tongue is pulled out and jaw braced forward and oropharyngeal airway placed in situ. In unconscious patient, endotracheal tube may be inserted to obtain positive airway control. In desperate condition, a 16 gauze needle pushed in cricothyroid space and connected to oxygen at the rate of 10–12 L/min.
Once the airway is cleared, the patient's respiratory effort is observed. Any sucking chest wound is closed by applying adhesive dressing and closing on three sides with adhesive plaster. In suspicion of tension pneumothorax 916 gauze needle with a finger stall at the other end with a small hole is pushed into second intercostal space. Patient with chest trauma if not contraindicated due to other injuries should travel propped up.
Most trauma patients have bleeding either external or internal. Pressure dressing is adequate for external bleeding, in case external bleeding not assessed by pressure dressing, pneumatic tourniquet should be used which can released intermittently.
Administration of Intravenous Fluid
In case of cardiac arrest:
  • Immediate establishment of airway, KVO is keep vein open
  • Ventilation with 100% oxygen
  • If feasible with an endotracheal tube
  • Initiation of external cardiac massage.
Cardiac tamponade is difficult to diagnose in field settings pericardiocentesis not feasible. Intravenous fluid loading and inotropic agents can tie over.
  • Splinting of fractured limbs
  • Patients must be strapped well on stretcher without pillow in supine position, if spinal injury is suspected.
Eviscerated of Viscera
Eviscerated of viscera not only give a ghostly look but also increase the shock, bleeding and subsequent infection. Clean sterile towel is enough to cover these and bandage loosely strapped and no attempt made to push intensive to avoid strangulation and twisting.
Prehospital Transport
The aim of transport is to decrease the time lag between the accident and definitive care. Prehospital transport systems are:
  • Ground ambulance
  • ALS ambulance
  • Air ambulance.
Status of Prehospital Care in India
Prehospital care is still in its infancy in India as compared to Europe and western countries. A large number of rural road accidents occur due to nonavailability of immediate care and delay in transport for definitive care to hospitals.10
Centralized Accident and Trauma Services (CATS) was started in Delhi on 15th March, 1991 with 27 ambulances. This is connected with wireless services at various points and manned with two paramedics and equipped with basic first aid and cardiopulmonary resuscitation (CPR) measures. But a very few people know the access number of CATS (1099). In Karnataka, State Highway accident service was started, service provided by Government of Karnataka. So, there is need for an area-based planning to provide early care and there is immediate need for training program in the area of first aid services and integrated trauma care.
Diagnosis Model
  1. Cardiac system: Acute myocardial infarction with complications:
    • Cardiogenic shock
    • Complex arrhythmias requiring close monitoring and intervention
    • Acute congestive heart failure with respiratory failure and/or requiring hemodynamic support
    • Hypertensive emergencies
    • Unstable angina, particularly with dysrhythmias, hemodynamic instability or persistent chest pain
    • Sudden cardiac arrest
    • Cardiac tamponade
    • Dissecting aortic aneurysms
    • Complete heart block.
  2. Pulmonary system:
    • Acute respiratory failure requiring ventilatory support
    • Pulmonary emboli with hemodynamic instability
    • Patients in an intermediate care unit, who are demonstrating respiratory deterioration
    • Need for nursing/respiratory care not available in lesser care areas such as floor or intermediate care unit
    • Massive hemoptysis
    • Respiratory failure with imminent intubation.
  3. Neurological disorders:
    • Acute stroke with altered mental status
    • Coma, metabolic toxic or anoxic
    • Intracranial hemorrhage with potential for herniation
    • Acute subarachnoid hemorrhage
    • Meningitis with altered mental status or respiratory compromise
    • Central nervous system or neuromuscular disorders with deteriorating neurological or pulmonary functions11
    • Status epilepticus
    • Brain dead or potentially brain dead patients, who are being aggressively managed, while determining organ donation status
    • Severe head injured patients.
  4. Drug ingestion and drug overdose:
    • Hemodynamically unstable drug ingestion
    • Drug ingestion with significantly altered mental status with inadequate airway protection
    • Seizures following drug ingestion.
  5. Gastrointestinal disorders:
    • Life-threatening gastrointestinal bleeding including hypotension, angina, continued bleeding or with comorbid conditions
    • Fulminant hepatic failure
    • Severe pancreatitis
    • Esophageal perforation with or without mediastinitis.
  6. Endocrine:
    • Diabetic ketoacidosis complicated by hemodynamic instability, altered mental status, respiratory insufficiency or severe acidosis
    • Thyroid storm or myxedema coma with hemodynamic instability
    • Hyperosmolar state with coma and/or hemodynamic instability
    • Other endocrine problems, i.e. adrenal crises.
  7. Hemodynamic instability:
    • Severe hypercalcemia with altered mental status, requiring hemodynamic monitoring
    • Hypermagnesemia or hypomagnesemia with hemodynamic compromise or dysrhythmias
    • Hypokalemia or hyperkalemia with dysrhythmias or muscular weakness
    • Hypophosphatemia with muscular weakness
    • Hyponatremia or hypernatremia with seizures, altered mental status.
  8. Surgical: Postoperative patients requiring hemodynamic monitoring/ventilatory support or extensive nursing care.
  9. Miscellaneous:
    • Septic shock with hemodynamic instability
    • Hemodynamic monitoring
    • Clinical conditions requiring ICU level nursing care
    • Environmental injuries (lightning, near drowning and hyporthermia/hyperthermia)
    • New/Experimental therapies with potential for complications
    • Any patient at risk for a precipitous, life-threatening event.