Critical Care Nursing

Debbie L. Dempel

History of Critical Care & ICUs

1930s Introduction of Recovery Rooms WWII & Korean War Concepts of triage and specialty nursing Late 1950s beginning of Critical Care Units Early Technology
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History Continued
Collaboration between nurses and physicians 1950s & 1960s CV Disease most common diagnosis 1960s 30-40% mortality rate for MI 1965 1st specialized ICU The Coronary Care Unit Emergence of Specialized ICUs
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American Association of Critical-Care Nurses - AACN

1969 Educational support Certification Largest professional specialty nursing organization Scholarships Research Publishes 2 journals Local chapters Political awareness Provides standards of practice

Critical Care Now

Critical Care Now

Nursing shortage 20% of patients spends time in a Half of patients in critical care unit ICUs >65 Downsizing In US critical care beds account for 8% Goal: provide high of all hospital beds quality, holistic care

Critical Care Technology

ECG monitoring Arterial Lines Oxygen Saturation Ventilation Intracranial Pressure Monitoring Temperature Pulmonary Artery Catheter IABP VAD Extensive use of pharmaceuticals

The Critical Care Nurse

Specialty dealing with human responses to life-threatening problems Requires Extensive Knowledge and a Continual Desire to Learn

CCRN
Critical Care Certification by AACN Requires:
Clinical hours working in an ICU Successful completion of an exam Requires continuing education and clinical hours for recertification

Critical Care Clinical Nurse Specialist (CCNS)

Advanced practice nurse Licensed by the State Five Roles of a CNS:
Patient & staff educator Consultant Administrator Researcher Expert practitioner
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Acute Care Nurse Practitioner (ACNP)

Advanced practice nurse Licensed by the State Provides comprehensive care to select critically ill patients

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The Critical Care Patient

Physiologically Unstable At Risk for Serious Complications Require Intensive and Complicated Nursing Support and/or Advanced Technology

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Common Problems of Critical Care Patients - Nutrition

Address it early Goal: prevent or correct nutritional deficiencies Parenteral Enteral

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Common Problems of Critical Care Patients - Anxiety

70-80% of patients Indicators agitation, increased BP, increased HR, verbalization, restlessness Treatment

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Common Problems of Critical Care Patients - Pain

70% reported moderate to severe pain 5th vital sign Leads to anxiety, agitation, increased myocardial oxygen consumption, delays wound healing

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Common Problems of Critical Care Patients Impaired Communication

Patient on the ventilator Use of medications Nursing Interventions

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Common Problems of Critical Care Patients Sensory-Perceptual Problems

ICU Psychosis Really Delirium 15-40% of patients Alteration in mentation Psychomotor behavior Alterations in sleep Predisposing factors

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Common Problems of Critical Care Patients Sleep Deprivation

Poor sleep/wake cycles Lack of REM sleep Predisposes patients for delirium Treatment

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Family Need of the Critical Care Patient

Information major source of anxiety and litigation Reassurance can reassure care is being given Convenience access to the patient

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Arterial Lines
Catheter placed in an artery Pressure from the artery is transmitted to a transducer by a column of fluid and converted in a pressure tracing Transducer must be placed at the Phlebostatic Axis 4th intercostal space Radial artery is the most common site
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Phlebostatic Axis

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Arterial Lines - Waveform

Systole aortic valve opens, blood ejected from LV, sharp rise in waveform Dicrotic Notch closure of the aortic valve, signifies the beginning of diastole Diastole lowest point recorded on the waveform

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Arterial Lines - Waveform

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Pulmonary Artery Catheter (SwanGanz Catheter)

Evaluate heart disease, shock states, compromised CO, and fluid status Also used to evaluate a patients response to treatment Catheter placed through a central vein to the right atrium, right ventricle, and into the pulmonary artery
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Pulmonary Artery Catheter (SwanGanz Catheter)

Measures Intracardiac Pressures Measures Cardiac Output Able to Obtain Mixed Venous Blood Samples

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Pulmonary Artery Catheter (SwanGanz Catheter)

1. 2. 3. 4. 5. Pulmonary Artery Port Central Venous Port Injectate Port Thermister Connection Balloon Inflation Valve

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PA Catheter

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PA Catheter Insertion

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Preload
Volume within a cardiac chamber at the end of diastole Pulmonary Capillary Wedge Pressure estimates the left ventricular enddiastolic pressure, 6-12 mm Hg Central Venous Pressure right ventricular end-diastolic pressure, 2-8 mm Hg
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Afterload
Refers to the forces that oppose ventricular ejection Systemic arterial pressure, resistance of the aortic valve, and mass and density of the blood Systemic Vascular Resistance

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Cardiac Output
Volume of blood pumped by the heart in 1 minute Normal: 4-8 L/minute Doesnt take into account body size More specific is Cardiac Index size adjusted by Body Surface Index

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Intraaortic Balloon Pump (IABP)

Balloon Catheter placed in the descending thoracic aortic arch Balloon inflation timed to begin to inflate at the time the aortic valve closes time of early diastole dicrotic notch

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IABP
Augments aortic pressure and forward flow Increases coronary perfusion When balloon deflates at end of diastole and aortic valve opens negative pressure pulls blood forward

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A: Systole-balloon Deflated, facilitates Ejection of blood to Periphery B: Early diastole Balloon begins to Inflate C: Late diastole Balloon is totally Inflated, augments Aortic pressure & Increases coronary perfusion
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IABP - Goals
Support patients with inadequate CO Support patients with inadequate BP

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IABP Common Indications

1. 2. 3. 4. Cardiogenic shock Left ventricular failure Cardiomyopathy Bridge to transplant

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IABP - Contraindications
Aortic aneurysm Aortic dissection Severe PVD Aortic Valve Insufficiency

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