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• Critical Care Units (CCU) or Intensive Care Units (ICU) can either be specialized (medical, surgical, cardiac) or nonspecific (combination of specialized cares).
• CCU/ICU specially trained staff maintains a 2:1 patient to staff ratio.
• Advanced equipment in the ICU setting may include IABP, ICP monitor, Arctic Sun, and ECMO; continuous monitoring of EKG, BP, temperature, ICP, and O2 sats.
• Advanced physical assessments and communication skills are crucial for critical care nurses.
• Certifications like CCRN and annual continuing education are often required.

E-ICU (Electronic ICU)

• Provides electronic or virtual monitoring of patients from another location.
• Benefits include extra eyes on the patient and vitals, trending data for anticipating changes, RNs with at least 5 years of critical care experience, and additional medical professional consultation.
• Cons include no physical contact with the patient, difficulty getting a feel for the patient's condition, and potential technical issues; E-ICU needs to be specifically requested and may not be available continuously.

Rapid Response Team (RRT)

• A collaborative team consisting of a critical care nurse adept at starting IVs, a crisis nurse, and a respiratory therapist.
• Other members include a doctor/APN who can assess, plan care, and implement nursing actions for unstable patients, using standing orders to order EKGs, labs, etc.
• Patients may need transfer to a higher level of care.

Patient Admission to ICU Reasons

• The patient is physiologically unstable, requiring advanced clinical judgment.
• Risk for serious complications necessitate frequent assessments and invasive interventions.
• Intensive support: IV medications and advanced technology may be required for ICP and ventilation.
• ICU is not for long-term coma or delaying death; death related to the severity of illness is common.

Progressive Care Units

• Progressive care units are designed to have a lower risk of complications than ICU environments.
• Continuous heart monitoring, long-term ventilator weaning, and minimal titrating drips.
• Progressive care units are a more cost-effective option and maintain a 3:1 patient to staff ratio.

Critical Care Patient Problems

• Impaired skin integrity due to immobility requires turning and linen changes every 2 hours.
• Additional challenges include healthcare-acquired infections, sepsis, nutritional concerns, anxiety, pain (often difficult to assess), sensory-perceptual disturbances, sleep disorders, and communication issues.
• Addressing sensory issues involves reorienting the patient and updating whiteboards.
• Communication challenges may arise if the patient is intubated or speaks another language.

Nutrition in the ICU

• Upon arrival to the ICU, patients are usually either hypermetabolic due to burns or sepsis, catabolic due to acute kidney injury, or malnourished with chronic heart/liver/lung disease.
• Malnutrition is associated with increased morbidity and mortality.
• Questions to consider about nutrition: who, when, what, and how to feed?
• Collaborative care involving dietitians and providers is essential to prevent or correct nutritional deficiencies.
• Enteral nutrition is less expensive, preserves the gut, and helps prevent bacterial translocation with options like OG, NG, Keofeed, or G-tube; early enteral nutrition can result in fewer complications and shorter hospital stays.
• Parenteral nutrition (IV) is used only when enteral feeding is not possible due to GI complications, trauma, or surgery.

Anxiety in ICU

• Anxiety is from pain, loss of control, sleeplessness, and feeling threatened.
• Anxiety stem from families, patients, and the setting such as lights, noise, hi-tech equipment, rapid pace.
• Clinical manifestations are increased BP & HR, agitation and restlessness.
• Nursing actions to reduce anxiety include encouraging questions, explaining procedure and equipment, adapting environment, anti-anxiety medication, music therapy, and relaxation techniques.

Family in ICU Contributions

• Loved ones help with the recovery process and should be included in teaching and cares
• The four main contributions to patient happiness are support, connection to personal life, help with healthcare decisions, and physical care
• Families have informational needs

Strategies to Assist ICU Patients & Families

• Provide continual updates, designate one representative to share information, and reassure and involve them in decision-making while respecting the need for convenience
• Explain equipment, encourage open visiting hours, and ensure patient openness

Cultural Perspective in ICU

• Address both physiologic and psychosocial needs, especially when dealing with death and dying
• Show respect cultural influences and approach sensitive topics cautiously

Pain Management in ICU

• 70% report having unrelieved pain with high risk related to infections and stress
• Contributing factors are stress, anxiety, agitation, invasive monitoring, immobility, scheduled procedures, post-op recovery, and neurological issues
• Provide an option for pain medication before PT

Sensory-Perceptual Problem in ICU

• ICU delirium is marked by alterations in mentation, variations in psychomotor conduct, and sleep-wake cycle difficulties.
• Contributing factors include environmental, demographic, physical, and medication, as well as time spent in ICU increases the risk.
• Nursing actions include decreasing sensory overload, increasing oxygenation, replacing electrolytes, providing a calendar and clock, reorienting the patient, and utilizing family for re-orientation and de-stressing; neuroleptic drugs may be considered.
• Defined as sudden confusion or changes in mental status.
• Delirium mainly affects person's attention, whereas dementia typically affects memory.
• Delirium has a temporary state that begins suddenly.
• Hyperactive delirium patients become overactive (agitated or restless), while hypoactive delirium patients become underactive (sleepy and slow).
• Confusion Assessment Method for ICU is acute onset of mental status changes or disorganised thinking = delirium.

Sleep Disorders in ICU

• Sleep disorders are due to procedures, pain, anxiety, noise, and medications can lead to reduced healing.
• Nursing care focuses on reducing sleep disruption, providing rest periods, bunching activities, and comfort.

Communication Problems in ICU

• Communication barriers include aphasia, intubation, paralysis, and language differences.
• Nursing interventions include using notepads, communication boards, computers, interpreters, nonverbal cues, and family participation, as well as utilizing a "Family Assessment Form."

Blood Flow

• Blood flows from superior and inferior vena cava R atrium tricuspid valve R ventricle pulmonary valve pulmonary artery lungs pulmonary veins L atrium mitral valve L ventricle aortic valve aorta.
• Diastole is relaxation of the myocardium
• Systole is the contraction of heart muscle, resulting in ejection of blood from ventricles.
• Action potential starts depolarization, leading to heart contraction.

Hemodynamic Monitoring

• Monitors pressure, flow, and oxygenation within the cardiovascular system.
• Assesses heart function, fluid balance (hypo/hypervolemic), and drug effects on cardiac output.
• Invasive and noninvasive means of devices measure hemodynamic parameters.
• External (noninvasive) device examples: BP cuff, EKG leads, SpO2.
• Internal (invasive) devices provide more accurate readings.

Hemodynamic Terms

• Cardiac Output (CO): is the volume of blood pumped by the heart in one minute (4-8 L/min).
• CO is equal to stroke volume multiplied by heart rate.
• Cardiac Index (CI) is the CO adjusted for body surface area (BSA) (2.2-4 L/min/m^2).
• CI calculation is cardiac output divided by BSA.
• Stroke Volume (SV): is the volume ejected with each heartbeat (60-150 ml/beat).
• Stroke volume is determined by preload, afterload, and contractility.
• SV calculation is cardiac output divided by heart rate.
• Stroke Volume Index (SVI): is SV adjusted for BSA (30-65 ml/beat/m^2).
• SVI calculation is CI/ HR.
• Central Venous Pressure (CVP): is the venous pressure at RA or vena cava (2-8 mmHg).
• Central Venous Pressure is the right atrial pressure that measures live data.
• Pulmonary Artery Wedge Pressure (PAWP): arterial pressure at PA (6-12 mmHg).
• Pulmonary Arytery Wedge Pressure is also known as the left ventricular preload or left ventricular end-diastolic pressure.
• Systemic vascular resistance (SVR): (800-1200 dynes/sec/cm^-5) is the opposition to blood flow by systemic vasculature.
• Pulmonary vascular resistance (PVR): (<250 dynes/sec/cm^-5) is the opposition to blood flow by pulmonary vasculature.
• Vascular resistance is the systemic and pulmonary resistance that reflects afterload.
• Contractility is the strength of ventricular contraction.
• No direct clinical measures of contractility exist.
• Positive inotropic drugs increase contractility and pump more blood.
• Examples of positive inotropic drugs: epinephrine, adrenaline, dobutamine, dopamine, digoxin
• Negative inotropic drugs decrease contractility.
• Examples of negative inotropic drugs: beta blockers, calcium channel blockers and antiarrhythmics.
• Preload is the volume within the ventricle at the end of diastole.
• Left ventricular preload or end-diastole.
• Pulmonary Artery Wedge Pressure reflects pressure measures pulmonary capillary pressure at PA
• Factors impacting include, but are not limited to, mitral valve dysfunction, intracardiac defect, and dysrhythmias.
• Right ventricle preload: aka right ventricle end-diastole
• Central Venous Pressure reflects right ventricular end-diastolic pressure
• Measure in right atrium of vena cava close to heart.
• Factors impacting tricuspid valve dysfunction.

Factors influencing preload

• Increases preload
• Hypervolemia, sympathetic nervous system stimulation, and exercise.
• Decreases preload
• Hypovolemia, impaired atrial contractions, increased HR, diuresis and vasodilation.

Afterload

• Forces opposing ventricular ejection, resistance left ventricle must pump to circulate blood.
• Systemic vascular resistance; resistance of systemic vasculature.
• Pulmonary vascular resistance; resistance of pulmonary vasculature.

Factors influencing afterload

• Increases afterload
• Hypertension, increased blood viscosity, aortic stenosis and regurgitation, valve resistance, ventricular radius and volume, and increased vascular resistance.
• Decreases afterload
• Mitral Valve Regurgitation, Left ventricular hypertrophy an decreased vascular resistance

Hemodynamic Monitoring: Oxygenation

• Arterial hemoglobin O2 saturation 95-100%
• Mixed venous hemoglobin O2 saturation of returning to right side of heart 60-80%
• Venous hemoglobin O2 saturation from venous blood from CVC should be 70%

Arterial Line

• Provides arterial BP for acute hypo/hypertension, respiratory failure, shock, neurological injury and includes measures: SBP, DBP, and MAP
• Invasive monitoring is more high/low accuracy than noninvasive
• Placement options: radial or femoral artery
• High/low pressure alarms based on patient condition
• Equipment must be referenced and zero balanced to environment
• Referencing: placing transducer is at level of atria of heart or phlebostatic axis
• The zeroring confirms that when pressure within system is zero, monitor reads zero
• Phlebostatic axis -atria middle between breast and back)
• The risks and complications with the risks of hemorrhage, infection and impairment and thrombus
• It improves accurate monitoring
• Assess neurological status to are line hourly
• Limb is will and take action if there is emergency
• Assess flush system per shift

Waveforms

• there's an arterial Wave after every contraction
• Dicrotic note: closing of the aorti valve
• Sysolic: highest point
• Diastoliv; losses point
• Adequately damped(normal) square wave lest
• The Underdamped line:
• Occlusion of waveform
• Arterial cathetere insertion

Arterial Pressure-Based CO

• Arterial Based are attachend
• Calculate and continuos CO(cci)
• Used to assess patient to fuilds
• Calculation is used to assess

Pulmonary Artery Pressure

• Swanz Ganz is pulmonary Artery Pressure
• Guiides the heart and long problems
• PA flow directed cathetar can treat lung damands
• Monitor ekg and heart

Central Venous Pressure

• This is a PA catheter with thermal fillament
• Senses temperature

Central Venous Pressures

• Hypovolemia, distubutive schok and venous diliaton
• High CVP
• Measuring cardiac output:
• PA catheter with thermal filament located in right atrium
• Senses change in temperature of blood as it passes through right ventricle

Noninvasive Monitoring:

Mean arterial pressure (MAP): average pressure in a patients arteries during one cardiac cycle

Pulse oximetry

• Can cause inaccurate readings d/t: - Vasopressors - Hypothermic Reposition probe

Nursing Management

• Circulatory support Provide interim support when:
• Recovering from acute injury
• Stabilizing before surgical repair
• Awaiting heart transplantation

Intra Aortic Balloon Pump (IABP):

• Provides temporary circulatory assistance by reducing afterload (helps support the heart by providing additional oxygenated blood to the heart)
• Consits - Suage-shaped balloon -Inserted in femoral artery and placed in descending thoracic aorta
  • Pump that inflates and deflates balloon (filled with helium)

Stages of Inflation

1. The control panel sincronices the baloon cycle.
2. Stages for temporary stages.
3. Contraindications when you cann’t use baloon .

Ventricular Assist Devices (VADs):

• Short and long-term support for failing heart
• Internal or external

Vascular Access

• Vein placement or catheter placement CVC: Triple or quad lumen - Discharged nome - For long-term IV antibiotics or chemo
  • PICC Line team Mediport: - Surgically implanted device on upper chest or arm

I###V Lines

• n ICU it's recommended to be large bore (18 g) Goal of oxygen therapy: keep SaO2 >92% or PaO2 >60 mmHg

Airway Management & Mechanical Ventilation

Noninvasive Airway:

Airway Adjuncts:

Stylette:

• Female = 7 ml
• Male = 8 ml.

Endotracheal (ET)Tube:

Endotracheal Intubation Procedure:

• Prior to Intubation - Consent Remove dentures and anything that may cause obstruction - Crash cart at bedside

Nursing Management- After proper ET tube placement:

Maintaining Tube Patency:

Nursing Management:

• Skin integrity"

Tracheostomy:

    -Long-term needs

Intubation

Rapid, concurrent administration of sedative and paralytic agents Decreases risks of aspiration and injury to

Levels of Sedation:

• Minimal normal to commands, cognitively sound
• Moderate / twilight/ conscious - Response purposefully ,Maintains patent airway,
• Deep
• depression of consiousness keep watch

Analgesics intubated for ventilation

If trying to intubate and fail

Timeline of Rapid Sequence Intubation

Mechanical Ventilation

• If the tube that connects the ET tube to ventilator pops off → start bag valve mask and get additional help to get pt reconnected, replace the circuit Provide assisted ventilation once pt has an airway

ventilation Positions

Mechanical Ventilation

PEEP

• Indications - Apnea
• Inability to breath/ protect airwa0.85 -Pulmonary embol

Central Venous Pressure (CVP

    - Distal port used for measure pressure""
    -Low CVP:
            -Hypovolemia
            -Distributive shock