Critical Care Final Study Guide
ICU Environment
Open ICU: physician responsible for pt. admits the pt. to ICU & keeps formal responsibility for
pt. & their tx. Intensivist is a consultant w/o primary responsibility
Closed ICU: pt. is admitted to ICU & responsibility for pt. & tx is transferred to intensivist
Sensory Overload
o Noise
o Bright lights
o Loss of privacy- multiple caregivers, people in & out of room
o Lack of nonclinical physical contact
o Emotional & physical pain
Confusion Lack of control
Sleep deprivation Thirst
Anxiety Pain
Depression Difficult communication
Sensory Deprivation
o Lack of visitors o White walls
o Staff stay out of room to give o No stimulation
privacy o Tv & phone $$
o
Modification of environment
o Noise reduction: soothing music, acoustical tiles/designs, private areas for
communication for caregivers & family members
o Adequate lighting: natural lighting, night/day synchronization
o Design of new units to promote health & safety: nature in the view, bring family into
experience
o Reorient every time you walk in the room!
o
o
o Palliative Care
Designed to relieve sx that negatively effect the pt. or the family
Should be implemented with all patients not just the dying
Elements:
o Early identification of end-of-life pts.
o Pain management
o Pharm & non pharm interventions to relieve: pain, anxiety, & other distressing sx
Pain Nausea
Anxiety Diarrhea
Hunger Confusion
Thirst Agitation
Dyspnea Sleep disturbance
Nursing interventions:
1
,Critical Care Final Study Guide
o Frequent repositioning o Peaceful environment
o Good hygiene o Pain relief
o Skin care o Spiritual needs
o
o End of Life Care in ICU
Prep the family—not an event but a process
Emphasizes comfort rather than cure
Philosophy of care, not a place
Views ding as a normal process
o Terminal Weaning
Let both the pt & family know what happens—may or may not pass away immediately
Ensure pt. is comfortable
Look right at the patient, make physical contact when explaining what is happening
Pain medication (morphine) enough to decrease WOB & antianxiety med (benzos)
o Titrate pain meds & sedation throughout relieves tachypnea, dyspnea, & use of
accessory muscles
o Ongoing assessment of response to therapy & comfort
Patient specific for comfort, ask about religious preferences
“Plug is pulled” by RN & RT
Comfort cart for family
Family may take part in post-mortem care
Unforeseen death, ET tube & IV left in until medical examiner is present
Family has a right to refuse autopsy however cannot refuse medical examiner
Up to family to call funeral home
If family wants to turn off the machine for the wrong reasons call ethics committee—no
longer need MD order
o
o MOLST Form
Mutually agreed on between the provider & pt. or surrogate
Clearly specifies the kind of care the pt. prefers at the end of life
o
o Ethics Committee
Multidisciplinary
Can say their finding contraindicates healthcare proxy’s request if it is immoral & unethical
petition court
Nurse’s share in the moral responsibility of their institution to ensure that the best ethical
decision making process is in place to meet pt. needs, uphold the institution’s philosophy, &
preserve the integrity of the nursing profession.
o Trauma
Look for mechanism of injury “ how did it happen?” , did their plane change? Height or
surfaces they fell from?
Prioritize tx to ABC’s
If neck is not stabilized stabilize w/ cervical collar—no backboards in NY
2
,Critical Care Final Study Guide
o Maintain C-spine immobilization until cleared by x-ray
Primary Survey: 1-2 mins, Airway, Breathing, Circulation, Disability, Expose
o Anterior only ; tag pt.
o Black deceased, not expected to survive
o Red immediate attention required
o Yellow delayed
o Green minor, “walking wounded”
Secondary Survey: after life threatening injuries are identified & treated
o Examination of all body systems
o Full set of v/s, focused interventions, comfort, hx, head toe
o PT, INR, H/H, lactic acid, type & crossmatch
o Tetanus toxoid administered
o Specialty consults
o Fluid resuscitation = LR!
o Falls
Spinal cord injury?
Can they move their extremities? Feel them?
Did they change their plane? Then cervical collar or immobilize neck & straighten midline
o Spinal Cord Injury
partial
Complete/ transection
Nursing Care:
o Test extremities for feeling/movement
o Level of feeling or sensation—is it functioning?
o Monitor LOC & urine output!
o Cervical SCI: assess respiratory rate & depth- use of accessory muscles; edema above C4
will affect respiratory status
o SNS dysfunction occurs w/ injuries at or above T6 autonomic dysreflexia (life threatening
HTN)
Monitor BP & heart above T6
Monitor GI above T6
Neurogenic bladder/bowel monitor below T10
Treatment
Methylprednisone (solumedrol) preserve neurologic function
Neurogenic bladder SP tube v. self-catheterize
if autonomic dysreflexia is suspected, take v/s & call MD!
o BURNS
o Thermal
Flames, scalding liquids, steam, direct contact with heat source
Cell injury by coagulation
Severity of injury r/t heat intensity & duration of contact
Children & elderly at greater risk at lower temperature
Thin skin & decreased agility in moving
3
, Critical Care Final Study Guide
o Chemical
Contact, inhalation of fumes, ingestion, injection
Severity r/t type, volume, duration of contact, concentration of agent
Tissue damage continues after agent neutralized
o Systemic Effects of Chemical
Acids – bathroom cleaners, swimming pool chemicals
o Necrosis of skin, can bind to serum Ca if taken po
Alkalies – oven cleaners, fertilizers
o Loosen skin P->liquefaction necrosis & seepage into tissues. Bind to P so hard to stop
burning process
Organic compounds – gasoline
o CNS depression, hypotension, hypothermia, pul edema, chemical pneumonitis, hepatic
& renal failure
o Warfare, terrorist attacks
Burns from chemicals or thermal exposure
Methamphetamine labs
o Inhalation, thermal & chemical burns
o
o Electrical
AC – alternating current (commercial)
Greater risk of v fib, “locks’ pt to electricity->resp muscle paralysis
DC – direct current – lightning, car batteries
Point of contact (entry & exit) injury depends on:
Type & pathway of current, duration, environment, body tissue resistance, cross section of
body involved
Urine output goal 75-100 mL/hr
o Inhalation
Injury from carbon monoxide
Binds to hgb better than O2->tissue hypoxia
Injury above glottis
Thermal- damage in pharynx& larynx, may cause airway obstruction
Injury below glottis
Chemical- impaired cilia, erythema, edema, hypersecretion, ulceration, increased blood flow,
bronchial spasm
o
o House Fires
When components of our homes burn
o Degrades into toxic substances
Carbon monoxide
Carboxyhemoglobin (COHgb) – binding of carbon monoxide to hgb
4
ICU Environment
Open ICU: physician responsible for pt. admits the pt. to ICU & keeps formal responsibility for
pt. & their tx. Intensivist is a consultant w/o primary responsibility
Closed ICU: pt. is admitted to ICU & responsibility for pt. & tx is transferred to intensivist
Sensory Overload
o Noise
o Bright lights
o Loss of privacy- multiple caregivers, people in & out of room
o Lack of nonclinical physical contact
o Emotional & physical pain
Confusion Lack of control
Sleep deprivation Thirst
Anxiety Pain
Depression Difficult communication
Sensory Deprivation
o Lack of visitors o White walls
o Staff stay out of room to give o No stimulation
privacy o Tv & phone $$
o
Modification of environment
o Noise reduction: soothing music, acoustical tiles/designs, private areas for
communication for caregivers & family members
o Adequate lighting: natural lighting, night/day synchronization
o Design of new units to promote health & safety: nature in the view, bring family into
experience
o Reorient every time you walk in the room!
o
o
o Palliative Care
Designed to relieve sx that negatively effect the pt. or the family
Should be implemented with all patients not just the dying
Elements:
o Early identification of end-of-life pts.
o Pain management
o Pharm & non pharm interventions to relieve: pain, anxiety, & other distressing sx
Pain Nausea
Anxiety Diarrhea
Hunger Confusion
Thirst Agitation
Dyspnea Sleep disturbance
Nursing interventions:
1
,Critical Care Final Study Guide
o Frequent repositioning o Peaceful environment
o Good hygiene o Pain relief
o Skin care o Spiritual needs
o
o End of Life Care in ICU
Prep the family—not an event but a process
Emphasizes comfort rather than cure
Philosophy of care, not a place
Views ding as a normal process
o Terminal Weaning
Let both the pt & family know what happens—may or may not pass away immediately
Ensure pt. is comfortable
Look right at the patient, make physical contact when explaining what is happening
Pain medication (morphine) enough to decrease WOB & antianxiety med (benzos)
o Titrate pain meds & sedation throughout relieves tachypnea, dyspnea, & use of
accessory muscles
o Ongoing assessment of response to therapy & comfort
Patient specific for comfort, ask about religious preferences
“Plug is pulled” by RN & RT
Comfort cart for family
Family may take part in post-mortem care
Unforeseen death, ET tube & IV left in until medical examiner is present
Family has a right to refuse autopsy however cannot refuse medical examiner
Up to family to call funeral home
If family wants to turn off the machine for the wrong reasons call ethics committee—no
longer need MD order
o
o MOLST Form
Mutually agreed on between the provider & pt. or surrogate
Clearly specifies the kind of care the pt. prefers at the end of life
o
o Ethics Committee
Multidisciplinary
Can say their finding contraindicates healthcare proxy’s request if it is immoral & unethical
petition court
Nurse’s share in the moral responsibility of their institution to ensure that the best ethical
decision making process is in place to meet pt. needs, uphold the institution’s philosophy, &
preserve the integrity of the nursing profession.
o Trauma
Look for mechanism of injury “ how did it happen?” , did their plane change? Height or
surfaces they fell from?
Prioritize tx to ABC’s
If neck is not stabilized stabilize w/ cervical collar—no backboards in NY
2
,Critical Care Final Study Guide
o Maintain C-spine immobilization until cleared by x-ray
Primary Survey: 1-2 mins, Airway, Breathing, Circulation, Disability, Expose
o Anterior only ; tag pt.
o Black deceased, not expected to survive
o Red immediate attention required
o Yellow delayed
o Green minor, “walking wounded”
Secondary Survey: after life threatening injuries are identified & treated
o Examination of all body systems
o Full set of v/s, focused interventions, comfort, hx, head toe
o PT, INR, H/H, lactic acid, type & crossmatch
o Tetanus toxoid administered
o Specialty consults
o Fluid resuscitation = LR!
o Falls
Spinal cord injury?
Can they move their extremities? Feel them?
Did they change their plane? Then cervical collar or immobilize neck & straighten midline
o Spinal Cord Injury
partial
Complete/ transection
Nursing Care:
o Test extremities for feeling/movement
o Level of feeling or sensation—is it functioning?
o Monitor LOC & urine output!
o Cervical SCI: assess respiratory rate & depth- use of accessory muscles; edema above C4
will affect respiratory status
o SNS dysfunction occurs w/ injuries at or above T6 autonomic dysreflexia (life threatening
HTN)
Monitor BP & heart above T6
Monitor GI above T6
Neurogenic bladder/bowel monitor below T10
Treatment
Methylprednisone (solumedrol) preserve neurologic function
Neurogenic bladder SP tube v. self-catheterize
if autonomic dysreflexia is suspected, take v/s & call MD!
o BURNS
o Thermal
Flames, scalding liquids, steam, direct contact with heat source
Cell injury by coagulation
Severity of injury r/t heat intensity & duration of contact
Children & elderly at greater risk at lower temperature
Thin skin & decreased agility in moving
3
, Critical Care Final Study Guide
o Chemical
Contact, inhalation of fumes, ingestion, injection
Severity r/t type, volume, duration of contact, concentration of agent
Tissue damage continues after agent neutralized
o Systemic Effects of Chemical
Acids – bathroom cleaners, swimming pool chemicals
o Necrosis of skin, can bind to serum Ca if taken po
Alkalies – oven cleaners, fertilizers
o Loosen skin P->liquefaction necrosis & seepage into tissues. Bind to P so hard to stop
burning process
Organic compounds – gasoline
o CNS depression, hypotension, hypothermia, pul edema, chemical pneumonitis, hepatic
& renal failure
o Warfare, terrorist attacks
Burns from chemicals or thermal exposure
Methamphetamine labs
o Inhalation, thermal & chemical burns
o
o Electrical
AC – alternating current (commercial)
Greater risk of v fib, “locks’ pt to electricity->resp muscle paralysis
DC – direct current – lightning, car batteries
Point of contact (entry & exit) injury depends on:
Type & pathway of current, duration, environment, body tissue resistance, cross section of
body involved
Urine output goal 75-100 mL/hr
o Inhalation
Injury from carbon monoxide
Binds to hgb better than O2->tissue hypoxia
Injury above glottis
Thermal- damage in pharynx& larynx, may cause airway obstruction
Injury below glottis
Chemical- impaired cilia, erythema, edema, hypersecretion, ulceration, increased blood flow,
bronchial spasm
o
o House Fires
When components of our homes burn
o Degrades into toxic substances
Carbon monoxide
Carboxyhemoglobin (COHgb) – binding of carbon monoxide to hgb
4
